Eligibility

Copy page

Eligibility Process Guide: Pre-Visit Authorization Workflow

Eligibility Process Guide: Pre-Visit Authorization Workflow

1. Overview: Authorizing an Elective Case Before the Visit

This guide covers the Pre-Visit Authorization workflow (POST /claims/authorize). For elective (planned, non-urgent) cases, the facility needs an authorization before the patient's visit day - there is no visit or claim yet. This workflow creates that authorization and returns it in AUTHORIZED_PENDING_VISIT status.

The token carried by that authorization object is what you later use to create the elective preauth, which is submitted before any visit exists. In other words, pre-visit authorization is the consent step that unlocks elective preauthorization.

1.1. What This Workflow Does

• Confirms Patient Consent Up Front: Verifies the patient's agreement via OTP or biometrics, just like the visit-day consent step.
• Creates a Pending-Visit Authorization: Produces an authorization in AUTHORIZED_PENDING_VISIT status that represents consent obtained before the visit.
• Issues the Token for the Elective Preauth: The authorization's token is passed as the consent_token when creating the elective preauth.

1.2. Why This Workflow Is Critical

• Enables Planning Ahead: Lets facilities secure authorization and preauthorization for planned procedures before the patient's visit day.
• Preserves Consent Integrity: Ensures elective preauths are still backed by verifiable patient consent (OTP or biometrics).
• Bridges to Elective Preauth: Provides the token that the Elective Preauthorization workflow depends on.

---

2. Workflow Details: Pre-Visit Authorization

2.1. Workflow Description

1. Input Reception: The system receives the patient_id, the service_type (INPATIENT or OUTPATIENT), the interventions, and the consent fields - either an otp (OTP path) or biometrics fields (work_station_id, agent_id).
2. Consent Verification: It verifies the OTP or the biometrics fingerprint match for the patient.
3. Authorization Creation: For an elective case (no visit yet), it creates an authorization in AUTHORIZED_PENDING_VISIT status.
4. Outcome Delivery: It returns the authorization object, whose token is used to create the elective preauth.

2.2. Key Validations

• Patient Must Be Identified: A valid patient_id is required.
• Valid Service Type: service_type must be INPATIENT or OUTPATIENT.
• Interventions Required: At least one valid intervention must be supplied.
• Consent Must Be Verified: Either a valid otp (OTP path) or valid biometrics fields (work_station_id, agent_id) must be provided and verified.

2.3. Workflow Data Dictionary

Field Name	Description	Data Type	Required	Purpose
patient_id	The patient's identifier.	String	Yes	Identifies the patient being authorized.
service_type	The category of service: INPATIENT or OUTPATIENT.	String	Yes	Classifies the planned encounter.
interventions	The planned interventions for the elective case.	Array	Yes	Details the services the authorization covers.
otp	The One-Time Password provided by the patient.	String	OTP path	Verifies patient consent on the OTP path.
work_station_id	The workstation ID from the Hardware Server.	String	Biometrics path	Identifies the biometrics device/workstation.
agent_id	The biometrics agent's National ID.	String	Biometrics path	Identifies the agent facilitating biometrics capture.

2.4. Expected Outcomes

• Authorization Created (AUTHORIZED_PENDING_VISIT): Consent was verified and an authorization was created ahead of the visit. Its token is used to create the elective preauth.
• Consent Verification Failed: The OTP was incorrect/expired or the biometrics match failed. No authorization is created.
• Input Error: A missing or invalid patient_id, service_type, or interventions prevented the request.

---

3. Critical Success Factors for Pre-Visit Authorization Integration

• Choose the Right Consent Path: Supply either otp or the biometrics fields (work_station_id, agent_id), based on the patient/facility. See the Biometrics Integration Guide.
• Hold the Token Securely: Store the authorization token so it can be passed as the consent_token when creating the elective preauth.
• Use With Elective Preauths Only: The AUTHORIZED_PENDING_VISIT flow is specifically for elective cases created before a visit exists. See Elective Preauthorization.

---

4. Related Resources

• Elective Preauthorization
• Biometrics Integration Guide
• Start Visit Workflow
• Eligibility Check Workflow