CareAffiliate Auto-Review and Approval Process

To reduce the time needed for preauthorization, we have identified several services for which requests can be automatically evaluated (auto reviewed). For these specific services, CareAffiliate compares the request to established criteria as follows: 

• If criteria are met, the preauthorization will be automatically approved with no further review required.
• If criteria are not met, the preauthorization request is automatically sent to medical staff for review. 

Preauthorization approved using this auto-review process will be examined to confirm that the clinical documentation submitted with request supports the authorized services. 

Each clinic will be reviewed periodically, drawing from random samples of their authorizations. Clinics need to pass this review with a 90% accuracy rate. When providers don’t achieve a passing score, Select Health will: 

• Provide personalized coaching on inconsistencies and recommendations to promote accurate documentation 
• Conduct a follow-up review to ensure recommendations have been instituted.
• Evaluate clinic eligibility for future auto-reviews only after three unsuccessful reviews.