MRI prior auth
Clinical packet ready
Workflow Use Case
Prior Auth & Payer Ops
Reduce manual payer work by combining benefits checks, prior auth workflows, portal automation, and follow-up into one operating flow.
Eligibility, prior auth, and follow-up stay in one work queue
Browser automation handles repetitive payer portal work
Aging and renewals stay visible before revenue is at risk
Operational picture
Payer work with less swivel-chair effort
Gather the packet, verify benefits, submit or update through payer workflows, and keep status visible across aging and renewals.
Signals
Eligibility feed
Payer portal
Payer call follow-up
Eligibility check
Coverage uncertain
Expiring auth
Renewal window open
Portal navigation
Status notes captured
Aging and renewal alerts
What Calvient handles
The real work inside this workflow
These are the operational motions the system has to coordinate well if the workflow is going to move cleanly.
Work queue
Eligibility and benefits work intake
Bring coverage checks, auth preparation, payer responses, and renewals into one queue with clear ownership.
Packet prep
Submission readiness and completeness
Check that clinical notes, codes, insurance details, and supporting records are present before the case goes out.
Browser agent
Portal automation where APIs do not exist
Use browser workflows to submit, check status, capture reference numbers, and update case notes without repetitive staff clicks.
Aging view
Status follow-up and renewal control
Track which authorizations are pending, denied, expiring, or aging by payer so follow-up stays proactive.
How it works
Structured execution from trigger to closure
The workflow should move because the system keeps state, ownership, and next action visible at every step.
01
Gather the required packet
Collect insurance details, clinical notes, CPT or service context, and any supporting documentation needed by the payer.
Cases are not pushed into payer workflows half-complete.
02
Verify coverage and readiness
Run eligibility and benefits verification to confirm the service pathway and expose missing information early.
The team knows whether the case can proceed and what evidence is still required.
03
Submit or update through payer workflow
Use portal automation, structured forms, or payer calls to move the case through the required operational path.
Submission status, reference numbers, and evidence are captured in the record.
04
Track aging, follow up, and renew
Keep pending cases moving, resolve denials or missing items, and start renewals before the authorization expires.
High-burden payer work is visible and manageable instead of reactive.
What operators see
Product views that move the workflow forward
These are the working surfaces that keep the queue understandable, actionable, and measurable.
Tasks
Payer work queue by next action
Staff can sort by eligibility, packet prep, submit, follow-up, denial, or renewal instead of working from disconnected payer lists.
CT auth request
Clinical packet ready to submit
PT eligibility check
Coverage details still unclear
Sleep study renewal
Expires in 5 days
- Owner and SLA by payer case
- Missing artifact flags
- Submit versus follow-up separation
Browser agent
Portal work with activity captured
Operators can see what the agent submitted, where it clicked, and what payer response came back.
Login + submit packet
Availity flow completed
Status recheck
Pending medical review
Exception flagged
Portal requested new clinical note
- Reference numbers recorded
- Portal outcomes logged
- Exceptions routed to staff review
Reporting
Aging and payer performance view
Managers can see where cases are piling up, which payers create the most rework, and where renewals are slipping.
Payer A
Longest turnaround this week
Payer B
Highest first-pass approval rate
Renewals
3 cases entering risk window
- Aging by payer
- First-pass completeness
- Rework and denial patterns
Workflow Views In Product
In Product
Auth work queue
Queue grouped by submit, follow-up, denial, and renewal states.
In Product
Browser automation activity
Payer portal task detail with logged actions and confirmation note.
Special Agents
Special Agents for this workflow
These agents are useful because they handle the repetitive middle of the workflow while leaving sensitive or ambiguous decisions with staff.
Payer portal submitter
Handles repetitive browser-based submission work and captures what happened for the record.
Trigger
Cases ready for payer portal submission or status review
Actions
- Navigate payer workflow
- Submit required fields and attachments
- Capture confirmation or status response
Handoff
Escalates portal exceptions, denials, or missing-data prompts to the auth team.
Auth status caller
Places structured follow-up calls when portal visibility is weak or payer rules demand phone confirmation.
Trigger
Aging cases or payers that require voice follow-up
Actions
- Call with case details ready
- Log structured outcome notes
- Schedule next follow-up step
Handoff
Routes unresolved or contradictory payer responses to the case owner.
Expiring auth renewal agent
Keeps expiring authorizations from becoming avoidable scheduling or billing problems.
Trigger
Cases approaching expiration or scheduled services beyond current auth window
Actions
- Open renewal work early
- Collect needed packet updates
- Queue or run payer renewal follow-up
Handoff
Escalates only when service dates, payer rules, or clinical context require human review.
Operational channels
The workflow moves across multiple channels without losing state
Payer operations run across portals, calls, documents, and internal queues. Calvient keeps the work in one operating loop.
Fax
Text
Phone
Browser
Forms
EHR / integrations
Fax
Payer responses, request letters, and supporting clinical documents
Text
Patient outreach when updated insurance or scheduling coordination is needed
Phone
Payer status calls, peer-to-peer coordination, and escalation work
Browser
Portal submission, status checks, evidence uploads, and renewal work
Forms
Structured auth packet prep and internal readiness checklists
EHR / integrations
Clinical note retrieval, chart context, and downstream scheduling coordination
Teams that use this
Deployment usually spans more than one team
This workflow usually crosses prior auth, revenue cycle, scheduling, and nursing review. The system needs to keep all of them on the same case state.
Prior Auth
Revenue Cycle
Authorization Nurses
KPIs / outcomes
Measure the outcomes that matter
The right operating system should make these measures easier to see, easier to improve, and easier to explain to leadership.
KPI
Auth turnaround time
How long authorizations take from work start to usable approval or resolution.
KPI
First-pass completeness
How often the first submission goes out without preventable missing items.
KPI
Rework rate
How often staff must reopen a case because information, status, or follow-up was incomplete.
KPI
Aging by payer
Which payer queues are creating the most delay and operational burden.
Related use cases
Explore adjacent workflows
Referral Management
Centralize inbound and outbound referral work, track status, request missing information, and move patients forward.
Operational Visibility & Reporting
Show queue health, backlog, turnaround time, productivity, and automation/reporting metrics.
Intake & Triage
Capture inbound work from fax, email, forms, and other channels, classify it, and route it to the right workflow.