What you can ask for

You ask for outcomes, not operations. Each skill below is a complete piece of work that we run to a conclusion or a documented stop.

#The skills

Skill	Ask it for	Ends at
`prior_auth_intake`	Get this procedure authorized.	A payer decision, or a documented stop before the wire.
`encounter_triage`	Which of these scheduled procedures need authorization?	A list, with anything undetermined named rather than assumed clear.
`auth_status_monitor`	What is the state of the authorizations you are holding for me?	A status list. Read-only.
`denial_triage`	This came back denied - what are the options?	A proposed next action and what it requires. Never an action taken.

#Asking whether something needs authorization

Often the only question you have. It is answered by asking the health plan about that specific member and procedure, so it needs a member id.

json

{
  "skill": "encounter_triage",
  "practiceId": "p_north",
  "patient": { "memberId": "MEM100200300" },
  "service": { "payerId": "BCBSF", "procedureCodes": ["27447", "99213"] }
}

json

{
  "codes": [
    { "code": "27447", "answer": "required",     "source": "payer" },
    { "code": "99213", "answer": "not_required", "source": "payer" }
  ]
}

#Three answers, not two

"unknown" is never "no"

Not every health plan will say. When one does not, you get "answer": "unknown" - and treating that as "not required" is the expensive mistake: the procedure goes ahead, nobody filed, and the claim is denied afterwards when nothing can be done. Route unknowns to a person.

#Answers can depend on network

json

{
  "code": "29881", "answer": "required", "networkDependent": true,
  "byNetwork": { "inNetwork": "not_required", "outOfNetwork": "required" },
  "note": "Confirm which network applies before relying on the alternative."
}

We roll up conservatively - if any applicable network needs authorization, the answer is required - and we keep the detail so you can show it.

#What we will not do

Decide medical necessity. We prepare paperwork; we do not judge the case.
Communicate a denial. An adverse determination goes to a licensed human at the practice, never to you as an action to take.
Guess a payer rule. Where nothing authoritative answers, we say so and stop.
Act without a release. At any level, for any customer.