Standard Operating Procedure
OPS-SOP-007 — Pre-Authorization Audit Cycle
1. Purpose
Establish a recurring audit cycle for reviewing and updating the pre-authorization list maintained by Allied TPA. This SOP ensures Unity proactively manages what procedures require pre-authorization based on claims data, enrollment trends, and cost patterns — rather than reacting after invoices arrive.
📋 Context (from Dr. Greg, March 4 Working Session)
"If we're getting mostly invoices from them, we don't want to probably do more frequent cycles to see, oh, we should probably adjust this way... a monthly audit cycle for the pre-authorization process that we would have to begin, based off of the claims involved and the enrollment information."
2. Scope
- In Scope: Review of Allied TPA pre-authorization list, claims pattern analysis, recommended additions/removals, cost impact assessment
- Out of Scope: Individual claim adjudication, member-facing pre-auth requests (Allied handles), clinical protocol decisions
3. Frequency
| Phase | Frequency | Rationale |
|---|
| Initial (Months 1-3) | Monthly | High volume of new data as plan launches. Need frequent calibration. |
| Steady State (Month 4+) | Quarterly | Sufficient claims history for pattern detection. Reduce operational burden. |
| Triggered / Ad Hoc | As needed | Major cost spike, new high-cost procedure trend, contract renegotiation |
4. Process Steps
1. Gather Data: Operations pulls the following from the most recent cycle:
- Weekly claims data from Allied (aggregate, no PHI)
- Monthly enrollment/premium data
- High-dollar claims report (any claim above [TBD] threshold)
- Provider concentration report
- Current pre-authorization list from Allied
2. Analyze Claims Patterns: Operations reviews data for:
- Procedures with highest cost impact
- Procedures with highest frequency increase vs. prior period
- Elective procedures not currently on pre-auth list
- Procedures on pre-auth list with low denial rates (may not need pre-auth)
- Provider-specific patterns (single provider driving disproportionate volume)
3. Draft Recommendations: Operations creates a recommendation memo:
- Procedures to ADD to pre-authorization list (with cost justification)
- Procedures to REMOVE from pre-authorization list (low impact, administrative burden)
- Threshold adjustments (dollar amounts, visit limits)
- Estimated annual cost impact of each change
4. Review with Leadership: Operations presents recommendations to Executive Leadership for approval. Include:
- Data summary (1-page max)
- Recommended changes with cost impact
- Risk assessment for each change
5. Submit to Allied: Once approved, Operations submits updated pre-authorization list to Allied TPA via [TBD — email / portal / formal change request]. Allied confirms receipt and implementation timeline.
6. Document and Close: Operations records:
- Date of review cycle
- Changes made (additions, removals, adjustments)
- Approval documentation
- Allied confirmation of implementation
- Next scheduled review date
5. Inputs
| Input | Source | Format |
|---|
| Weekly claims register | Allied TPA | Secure file [TBD] |
| Monthly premium/enrollment data | Allied TPA | Invoice + enrollment file |
| Current pre-authorization list | Allied TPA | [TBD — request from Allied] |
| High-dollar claims report | Operations (derived from claims data) | Excel / tracking tool [TBD] |
| Stop-loss threshold data | Reinsurance Broker (Jason Strain / Brown & Brown) | Policy schedule |
6. Outputs
| Output | Destination | Format |
|---|
| Pre-Auth Audit Summary | Executive Leadership | 1-page memo |
| Recommended Changes | Executive Leadership → Allied | Change request form [TBD] |
| Updated Pre-Auth List | Allied TPA | Per Allied requirements |
| Cycle Close Documentation | Retention / compliance files | Audit log entry |
7. RACI
| Activity | R | A | C | I |
|---|
| Gather claims/enrollment data | Operations | Operations | Allied TPA | |
| Analyze patterns | Operations | Operations | | |
| Draft recommendations | Operations | Operations | Finance | |
| Approve changes | Executive Leadership | Executive Leadership | Operations, Legal & Compliance | Finance |
| Submit to Allied | Operations | Operations | | Executive Leadership |
| Confirm implementation | Allied TPA | Operations | | Executive Leadership |
8. Escalation
| Trigger | Action | Owner |
|---|
| Claims spike >25% vs. trailing average | Trigger ad hoc pre-auth review immediately | Operations |
| Allied does not implement changes within [TBD] days | Escalate to account manager (Kim James) | Operations |
| Leadership does not approve within 5 business days | Escalate with cost impact summary | Operations |
9. Open Items
🔴 Required Before First Cycle
- Obtain current pre-authorization list from Allied — [TBD]
- Confirm Allied's process for updating pre-auth list (email? portal? formal change request?) — [TBD]
- Define high-dollar claim threshold — [TBD]
- Confirm claims spike trigger percentage — suggested 25% but needs validation
- Build tracking tool/Excel for cycle documentation — see OPS-SOP-007 tracking tool
OPS-SOP-007 | Unity Care Solutions, LLC — Internal / Confidential
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