Healthcare scenario: Simplify prior authorization(PA)
Available with: Microsoft 365 Copilot and Copilot Studio Scenario level:
KPIs impacted
Claims processing time
Value benefit
Cost savings
Using Copilot to simplify prior authorization(pa)
1. Summarize request
Use a Copilot agent to summarize relevant information for the incoming PA request by analyzing relevant information from prior authorization forms, medical records, and coverage policy documents.
Copilot Studio Agent
Benefit: Reduces manual effort and ensures comprehensive data extraction for accurate decision-making.
2. Validate PA request
Use a Copilot agent to compare and validate identified services against prior authorization guidelines by extracting information from medical records and coverage policy documents.
Copilot Studio Agent
Benefit: Helps ensure compliance with guidelines and improves the accuracy of service validation.
3. Collaborative review
Utilization Management (UM) team members use Copilot Pages to collaboratively review/ refine and have interactive discussions on summarized information on incoming PA request.
Microsoft 365 Copilot Chat2
Benefit: UM team can collaboratively review a comprehensive summary, thus reducing time in understanding member’s prior history.
4. Decision support for PA request
Use the agent to offer detailed considerations designed to assist UM team members with decision making around approval, denial, or pend status. This can be based on specified rules and guidelines and past decisions on similar cases.
Copilot Studio Agent
Benefit: Streamlines the decision-making process and ensures consistency in authorization decisions.
5. Draft decision letter
Upon final decision being made, use the agent to draft an authorization letter in the member's preferred language based on the suggested template to include a member summary, and appropriate denial codes, etc.
Copilot Studio Agent
Benefit: Enhances member experience by providing communication in their preferred language and required timeline.
1Access Microsoft 365 Copilot Chat at m365copilot.com or the Microsoft 365 Copilot Chat mobile app and set toggle to “Web".
2Access Microsoft 365 Copilot Chat at mm365copilot.com, the Microsoft 365 Copilot Chat mobile app or the Microsoft 365 Copilot Chat app in Microsoft Teams, and set toggle to “Work”.
3Copilot agents allow Microsoft 365 Copilot to access your organization-specific apps. In the past, this would have required an API call to get data from a system of record. The content in this example scenario is for demonstration purposes only. You should evaluate how Copilot aligns with your organization’s business processes, regulatory requirements, and responsible AI principles.
The content in this example scenario is for demonstration purposes only. You should evaluate how Copilot aligns with your organization’s business processes, regulatory requirements, and responsible AI principles.
