Prior Authorization and 340B AI Solution

The Vendor is required to provide a technology-enabled solution to streamline the prior authorization process with support through Artificial Intelligence (“AI”).
- The service should support both authorizations through both pharmacy and medical insurance benefits on medication authorizations including both specialty and infusion therapies.
- The need for this service is driven by the significant increase in authorization volume and complexity which results in manual workflows that could delay therapies and put additional strain on staff.
- The solution should be scalable to support increasing volume and staffing.
- The solution should also deliver measurable efficiency improvements, provide reporting and analytics to monitor utilization, turnaround times, and performance as volumes continue to expand.
- Each pharmacy authorization can take 10-20 minutes, while medical authorizations can take 20-30 minutes on average depending on the complexity.
- Support the management of 50,000 – 75,000 retail 340B program claims per month and claims auditing workflows to drive compliance, recapture, and referral capture opportunities.
- Provide end-to-end support across pharmacy and medical benefit prior authorizations (“PA’s”), specialty and infusion authorizations, and 340B optimization.
- Provide a web-based user interface for PA tracking with the ability for real-time status overview and updates.
- The ability to utilize disease and drug specific intelligence to enhance the full PA workflow.
- The ability to ensure accuracy on complex clinical questions.
- The ability to contact payors (dialing through IVR trees) to obtain status updates on prior authorizations, appeals and other coverage determinations.
- The ability to demonstrate a first pass insurance authorization approval rate of over eighty percent (80%).
- Unlimited account support twenty-four/seven (24/7).
- Onsite training for system implementation and use of software initial training.
- Provide real-time visibility of pharmacy operations data and analytics across the platform including but not limited to metrics for PA throughput, approval/denial rates, and turnaround times.
- Provide reports to show insurance approval and denial rates.
- Provide real time 340B analytics for optimization and auditing of the program.
- The ability to identify and flag claims previously determined to be ineligible by the Third-Party Administrator (“TPA”), EPIC or pharmacy management system and must cross reference Upstage’s eligibility criteria to flag those claims for additional employee review (“missed opportunities”).
- The solution manages prior authorizations that need to be escalated for follow-up and/or need intervention.