Hub Services · Technical View

Prior Authorization & Benefit Verification — Technical Architecture

Sarah PA/BV Voice Agent · Patient Access workflow · BCBS Pennsylvania · VYVGART

Step 01

Patient Data Collection

CALL 1 · Outbound

Fields captured

patient_dobmember_idgroup_idplan_namerx_binrx_pcnbenefit_typesubscriber_type

Validation: Identity verified against enrollment form · 2-attempt max

Fallback: Human transfer if identity unconfirmed

Step 02

Clinical Criteria Validation

AUTO · Knowledge Base

✓ diagnosis_confirmed = gMG (G70.00 / G70.01)

✓ achr_positive_confirmed = true

✓ prior_therapies ≥ 1 documented (pyridostigmine / prednisone / azathioprine)

✓ concurrent_biologic = false (Soliris / Ultomiris / Zilbrysq check)

⚠ If concurrent_biologic = true → STOP + human escalation

Step 03

Eligibility & Benefit Verification

PRIMARY · 270/271 EDI

PRIMARY · CLEARINGHOUSE · 270/271 EDI

Real-time electronic eligibility & benefit check via clearinghouse (Stedi)

270 inquiry → 271 response returns: coverage active, plan type, deductible met/remaining, OOP max, PA-required flag, drug benefit channel

Returns in seconds — no phone call needed when the payer is EDI-enabled

FALLBACK · CALL · when payer is not EDI-enabled

Phone: 1-888-678-7012

IVR path

Press 2 (Provider)→Press 2 (PA)→Press 1 (Pharmacy)→Enter member_id→Enter DOB→Hold → PA Specialist

Timeout: 8 min max · Fallback: CoverMyMeds ePA

Step 04

PA Submission

LIVE · PA Specialist

Step 05

PA Reference Capture

CAPTURE

Fields logged

pa_reference_numberexpected_decision_dateadditional_docs_requiredinsurer_fax_number

⚠ If LOMN requested → flag to physician office

⚠ If peer-to-peer required → schedule neurologist ↔ medical director call

Step 06

D365 Write-back + PHI Wipe

WRITE · D365

D365 fields written (14)

case_statuspa_reference_numberauth_start_dateauth_expiry_dateapproved_unitsapproved_dosehcpcs_codeicd10_codepayer_nameplan_typebenefit_typedeductible_remainingoop_remainingdenial_reason

After write: PHI fields zeroed from memory.

case_status: approved | denied | pending

⚠ If denied → denial_reason captured → appeal workflow triggered

Sarah's Active Memory

● LIVE

Case UBC-2026-008441

captured pending flagged