Connecting prior auths to the getMiscBillingOptions method

juggernautsei · May 22, 2023, 7:25pm

I am putting around in the billing again trying to find a way to collect the information that is in the prior auth table to be consumed in the billing. I am trying to automate the process. Since the prior auth table has the CPTs. We should be able to match the active auth to the claim and enter the auth number.

What are your thoughts on this automation?

If anyone has done this already. Care to share. @mdsupport

stephenwaite · May 23, 2023, 10:44am

hi @juggernautsei, maybe you could have a listener when saving the fee sheet?

mdsupport · May 23, 2023, 3:26pm

Is there any codified information in prior auth form?

Describe the flow you have in mind.

juggernautsei · May 24, 2023, 4:36pm

Hi @stephenwaite , I can’t picture how that would work seeing in the code that the auth right now is saved in the form_misc_billing_options. What do you envision the listener doing?

@mdsupport in the advanced prior auth table. The auths are saved with the billing codes that are associated with them. So, there is some codified information in the table. The table contains the auth expiration date.

I was thinking about expanding this into another class or expanding the logic here. The system would need to get a list of the auths that are not expired. Then, the system would need to look at the CPT codes for that encounter to determine if there is a match to any of the auths that are not expired.

If a match is found, return the auth.

github.com

openemr/openemr/blob/48ec310a7954d304aa0b11fadea408e9f6813648/src/Billing/Claim.php#L169


      
          }
          
          public function getInsuranceNumbers($payer_id, $provider_id)
          {
              $sql = "SELECT * FROM insurance_numbers " .
                  "WHERE (insurance_company_id = ? OR insurance_company_id is NULL) AND provider_id = ? " .
                  "ORDER BY insurance_company_id DESC LIMIT 1";
              return sqlQuery($sql, array($payer_id, $provider_id));
          }
          
          public function getMiscBillingOptions($pid, $encounter_id)
          {
              $sql = "SELECT fpa.* FROM forms JOIN form_misc_billing_options AS fpa " .
                  "ON fpa.id = forms.form_id " .
                  "WHERE forms.pid = ? AND forms.encounter = ? AND " .
                  "forms.deleted = 0 AND forms.formdir = 'misc_billing_options' " .
                  "ORDER BY forms.date";
              return sqlQuery($sql, array($pid, $encounter_id));
          }
          
          public function getReferrerId()

In theory, the auth would have to be matched by pid, cpt, and expiration date greater than today.

stephenwaite · May 24, 2023, 4:55pm

when the fee sheet is saved check the mbo table and see if an auth is there and display it, if not then try to find one in the prior auth module?

mdsupport · May 24, 2023, 8:36pm

Is it form_prior_auth table? Or maybe I am clueless so I better sign off. Before doing that, here is an excellent overview of where business is headed. So it will help this project if all development efforts are directed towards implementing one or more process boxes.

Best.

juggernautsei · May 24, 2023, 8:53pm

@mdsupport
module_prior_authorizations is the table in the database where the data is stored.

juggernautsei · May 24, 2023, 8:54pm

@stephenwaite what is the purpose of displaying it? Shouldn’t it be inserted in the claim during the claim processing?

stephenwaite · May 24, 2023, 8:55pm

it can’t be inserted if it isn’t in the mbo table

thinking that it would be an enhancement because currently when the biller goes to the manager only a green button would indicate if there’s something in the mbo but doesn’t provide any info unless that button is clicked and the mbo is opened

juggernautsei · October 2, 2025, 8:21pm

@stephenwaite Two years have passed!! I am back around to this again. I am going to pick this up again shortly. I would really like to get this automated more. Since the authorization has CPTs attached to it. That is enough information during the billing process to pull the right auth for the claim. I have modified the Claim.php to include this information if it exists. That is working. What is concerning me is the diagram which @mdsupport brought to the table. I was revisiting it. The external connections are available now. CMS has made it mandatory that payers make the PA process easier through APIs. I have been unable to find them. Do any of you know of a PA API provider for procedures?

stephenwaite · October 3, 2025, 4:20pm

nice @juggernautsei !

@adunsulag mentioned the other day this will be part of a future certification effort

juggernautsei · October 3, 2025, 5:21pm

@stephenwaite @adunsulag I found the ruling while chasing down the pain point of prior authorizations for medical procedures. I have not found a insurance provider or clearinghouse that is providing those API/FHIR services as of today. I know it is slated to go into affect Jan 2026. I am in the process of building out the Ensora (formerly New Crops) interface to managing claims, and auto posting remits. The only prior authorization I can find is for ePrescribing. That is built into Ensora’s interface as of now. It will show which drugs require a prior auth and which ones don’t that are comparable. I confirmed that this week.

What is outstanding is the prior authorizations for treatments. An interface that assists the clinic to know which precedures need prior auths for and a way to electronically submit all of the documentation is what I am looking for. I know this is going to relegated to the clearinghouse and there will need to be an interface built to plugin different clearinghouses to populate the prior auth table.

There is a thread out there where a provide connected the prior auths to the clinical alerts. That should be looped in so that it can kick off the renewal process automagically.

stephenwaite · October 3, 2025, 5:46pm

sounds great, hope you contribute it back to the community!

juggernautsei · October 3, 2025, 7:00pm

I ready through their site which read as all internal use.

I filled out their application but it is the same questions that every vendor ask. How many this and how many that and why should we talk to you kind of questions. I will let you know how this works out as well as all the other applications I have in.

@stephenwaite I have the desire to give back to the community but the community needs more gate keepers. I have a lot of stuff out on the shelf that is just molding away. I know you guys are swamped. I really get it. But I is a disincentive make a PR that just sits and gets passed over for long time. I have things I can include in the codebase like the AWS S3 module. It is just sitting on the shelf and I gave it away to two people this year. The seem to enjoy the module. It is working well for both. And there are more.

P.S.

I filled out the applications and got an immediate response. I replied just now and explained what I am trying to accomplish. Let’s see where blue pill takes me.

juggernautsei · October 5, 2025, 12:35pm

I have not heard back from Availity as of yet.

I kept looking and I found this page.

I will call them tomorrow, Monday, to see if I can get someone on the phone.

@adunsulag Can I claim this feature build for the future certification effort?

UPDATE: 2025-10-19

I have an upcoming meeting with availity to kick off talks.

I also had a meeting with WayStar. Chris at WayStar explained the current situation with the medical prior auths and what they are doing. It is a work in progress but they have some ground work they have done. They only have these specialties ambulatory, surgery centers, cardiology, and radiology. Is is a start of something big. I hope. WayStar will own the client. This will be a give away for me.

juggernautsei · November 5, 2025, 9:21pm

I had two meetings this week and last with WayStar and Availity.

The deal with WayStar:

We will build out a module that will connect the program to WayStar’s interface for the prior auths. The clinic will have to contract directly with WayStar for services.

The deal with Availity:

We need a boatload of providers to build out the Availity solution for prior auths. Their platform structure is not direct to the provider. There has to be a man in the middle. To fulfill the man in the middle role. We need 40 registered early adopters to sign up at $25 each. Or this will never be built. Our incentive to the early adopters is that you will never be charged a transaction fee, and your subscription amount will never increase.

If you are interested in this project coming to the platform, PM me and I will let you know what to do. There is a 30-day window on this offer. The second week in December. This Availity project will close. I will update this thread with the results. Whether we are moving ahead or we are dead in the water.