Referral & Prior Auth Gateway

Principal workflows

• Intake: Referrals and orders arrive from your EHR into one worklist, by department and urgency.
• Eligibility and benefits: Coverage is checked electronically and the response stored with the referral, so problems surface before scheduling.
• Authorization: Payer rules decide whether authorization is needed. Where it is, the request is assembled from the order and clinical documentation and submitted electronically where the payer supports it.
• Follow-up: Pending, approved, denied and expiring authorizations are tracked, with requests for more information routed back to the right person and outcomes written back to the referral.

Who uses it

• Referral coordinators and prior authorization specialists
• Patient-access and scheduling teams
• Revenue-cycle and denial-management leaders
• Clinic and department managers
• Clinicians and their staff, who supply documentation when asked

Reporting

• Open referrals and authorizations by queue, payer, service and age
• Items with an appointment coming up and no authorization decision
• Authorizations due to expire, and units nearly used
• Requests for more information outstanding, by who they are waiting on
• Denials by payer, service and stated reason, for appeal and contracting conversations
• Submission route by payer: electronic, API or portal, to show where manual work remains

Features

• One worklist: Every referral and authorization in one place, sorted by urgency and appointment date.
• Payer rules library: Which services need authorization from which payer and plan, maintained in one place with the date each rule was last reviewed.
• Electronic eligibility: X12 270/271 coverage checks through your clearinghouse, stored with the referral.
• Electronic submission: X12 278 through your clearinghouse, and payer prior authorization APIs where payers provide them.
• Documentation packets: The order, notes and results the payer asks for, gathered from the EHR into one request.
• Clinician requests: When documentation is missing, a specific request goes to the ordering clinician's team, not a general message.
• Status tracking: Decisions, pends and expiry dates tracked, with reminders before an authorization lapses.
• Authorization details: Authorization number, approved units, valid dates and site or provider restrictions recorded and checked against the appointment.
• Denial follow-up: Denials routed with the payer's reason for peer-to-peer review or appeal, with the history kept together.
• Portal hand-off: For payers without an electronic route, the request is prepared in full so a specialist can submit it on the payer's portal and record the result.
• Write-back to the EHR: Status and outcomes written back to the referral, so scheduling and billing work from the same facts.
• Audit trail: Every check, submission, response and change recorded with who did it and when.

Integrations

• EHR orders and referrals: Orders and referrals received through HL7 v2 or FHIR interfaces.
• EHR documentation: Clinical notes and results retrieved for the request packet through FHIR or document interfaces.
• EHR write-back: Status, authorization numbers and outcomes written back to the referral.
• Clearinghouse: Eligibility and authorization transactions through the clearinghouse you already use.
• Payer APIs: FHIR-based coverage requirements and prior authorization APIs following the HL7 Da Vinci guides, where payers offer them.
• Scheduling: Appointment dates read from your scheduling system so work is sorted by when the patient is due.
• Single sign-on: Staff sign in through your identity provider (SAML or OpenID Connect).
• Work API: Worklist and outcome data available to your reporting and analytics tools through the Moraph Work API.

Deployment

• Moraph cloud: Hosted by Moraph in the United States region, under a business associate agreement.
• Dedicated environment: Single-tenant hosting where your policies require it, scoped in the proposal.
• Phased rollout: Can start with one department, service line or set of payers and expand under the same configuration.
• With a managed service: Optionally paired with a Moraph managed service for interface monitoring and platform administration.

Security and privacy

• Business associate agreement: Moraph signs a business associate agreement covering the protected health information the Gateway processes.
• Encryption and key control: Client data is encrypted, with keys Moraph staff cannot access without explicit, time-bound authorization, as described in our Trust Center.
• Role-based access: Staff see the queues and records their role needs, and administrators control who has which role.
• Minimum necessary: Request packets include the documents the payer's requirements call for, not the whole chart.
• Audit logging: Every view, change, submission and export is logged with the user and time, and available for your compliance reviews.
• Independent assurance: The Gateway runs within Moraph's SOC 2 Type II and ISO/IEC 27001 programs; reports are available under confidentiality terms through the Trust Center.

Limitations

• Where a payer accepts requests only through its own portal, the Gateway prepares the request and a specialist submits it there.
• Medical-necessity documentation comes from your clinicians. The Gateway gathers it; it does not write it.
• Approval decisions are the payer's. The Gateway makes requests complete and visible, but cannot guarantee an outcome.
• Payer rules are configured with you during implementation and need to be kept current as payer policies change.
• Payer prior authorization APIs are only used where a payer offers one and the connection has been set up; availability varies by payer.
• Electronic eligibility and 278 transactions depend on your clearinghouse supporting them for each payer.
• It does not submit claims or post payments. It works alongside your billing system.
• Appeals are tracked and supported with the request history, but appeal letters are written by your staff.

Next steps

Book a demonstration or a technical briefing at www.moraph.com/solutions/referral-prior-auth-gateway. Purchasing routes and company information: www.moraph.com/how-to-buy.