Workflow

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Delivering speed, accuracy, and efficiency across every step.

STEP 01 / ELIGIBILITY

Eligibility & Benefits Verification

Instant access to patient copay, deductibles, and out-of-pocket costs. Calculates Patient Financial Responsibility to provide an accurate cost estimate.

INSURANCE A · PRIMARY

Active

Co-Pay

$40

Co-Insurance

20%

Deductible Remaining

$188

Patient Responsibility

$228

STEP 02 / VERIFICATION

Authorization Verification

Checks if authorization is needed through payer guidelines. In cases of authorization on file, reads prior approvals and denial letters, and evaluates visit counts for accurate next-DOS evaluation.

PAYER RULE CHECK

UHC · ONC POLICY v2024.3

Authorization required

J9263 · Oxaliplatin

Auth on file

· 3 visits remaining

No prior denial

clear to submit

STEP 03 / MEDICAL NECESSITY

Medical Necessity Assessment & Recommendation

Leverages evidence-based and payer guidelines to create automated checklists, assessing each item to provide clear approval or denial recommendations.

REGIMEN: FOLFOX · ICD-10 C50.912

CRITERIA 4/5

One of the following criteria should be met:

Combination therapy with fluorouracil-based chemotherapy regimens;OR

J0640: Injection, leucovorin calcium, 50mg

J8540: Fluorouracil, oral, 500mg

J9263: Injection, oxaliplatin, 0.5mg

●

CRITERIA MET · CLEAR FOR APPROVAL

STEP 04 / SUBMISSION

Prior Authorization Submission

Auto-populates and submits PA forms with all required clinical documents and questionnaires.

PACKET — PATIENT 4821 · FOLFOX

PA Form

· UHC standard

FILED

Clinical Notes

· 4 attached

FILED

ICD-10 + HCPCS

· C50.912 / J0640+

FILED

Questionnaire

· auto-populated

FILED

STEP 05 / TRACKING

Real-Time Status Tracking

Constant updates and real-time status tracking from payer portals, e-fax, and email — no portal logins required from your team.

CASE 4821 · ACTIVITY

UPDATED 2m AGO

Submitted via payer portal

Apr 22 · 09:14

Received by UHC

Apr 22 · 09:16

Under clinical review

now · ETA 2-3 Days

Determination

pending

STEP 06 / APPEALS · NEW

Automated Appeal Letters

Best-in-class appeal letters crafted by analyzing research and medical necessity guidelines — drawing directly on the payer's own policy language.

APPROVED APPEAL LETTER

(ICD-10: C34.90, Malignant Neoplasm of the Lung)

The patient's diagnosis is a covered condition per the Oncology Benefits policy. The requested regimen aligns with NCCN guidelines for the stated line of therapy and satisfies medical necessity criteria on file.

— OneRISA, Medical Necessity Appeals Engine

STEP 01 / ELIGIBILITY

Eligibility & Benefits Verification

Instant access to patient copay, deductibles, and out-of-pocket costs. Calculates Patient Financial Responsibility to provide an accurate cost estimate.

INSURANCE A · PRIMARY

Active

Co-Pay

$40

Co-Insurance

20%

Deductible Remaining

$188

Patient Responsibility

$228

STEP 02 / VERIFICATION

Authorization Verification

Checks if authorization is needed through payer guidelines. In cases of authorization on file, reads prior approvals and denial letters, and evaluates visit counts for accurate next-DOS evaluation.

PAYER RULE CHECK

UHC · ONC POLICY v2024.3

Authorization required

J9263 · Oxaliplatin

Auth on file

· 3 visits remaining

No prior denial

clear to submit

STEP 03 / MEDICAL NECESSITY

Medical Necessity Assessment & Recommendation

Leverages evidence-based and payer guidelines to create automated checklists, assessing each item to provide clear approval or denial recommendations.

REGIMEN: FOLFOX · ICD-10 C50.912

CRITERIA 4/5

One of the following criteria should be met:

Combination therapy with fluorouracil-based chemotherapy regimens;OR

J0640: Injection, leucovorin calcium, 50mg

J8540: Fluorouracil, oral, 500mg

J9263: Injection, oxaliplatin, 0.5mg

●

CRITERIA MET · CLEAR FOR APPROVAL

STEP 04 / SUBMISSION

Prior Authorization Submission

Auto-populates and submits PA forms with all required clinical documents and questionnaires.

PACKET — PATIENT 4821 · FOLFOX

PA Form

· UHC standard

FILED

Clinical Notes

· 4 attached

FILED

ICD-10 + HCPCS

· C50.912 / J0640+

FILED

Questionnaire

· auto-populated

FILED

STEP 05 / TRACKING

Real-Time Status Tracking

Constant updates and real-time status tracking from payer portals, e-fax, and email — no portal logins required from your team.

CASE 4821 · ACTIVITY

UPDATED 2m AGO

Submitted via payer portal

Apr 22 · 09:14

Received by UHC

Apr 22 · 09:16

Under clinical review

now · ETA 2-3 Days

Determination

pending

STEP 06 / APPEALS · NEW

Automated Appeal Letters

Best-in-class appeal letters crafted by analyzing research and medical necessity guidelines — drawing directly on the payer's own policy language.

APPROVED APPEAL LETTER

(ICD-10: C34.90, Malignant Neoplasm of the Lung)

— OneRISA, Medical Necessity Appeals Engine

Workflow

Delivering speed, accuracy, and efficiency across every step.

STEP 01 / ELIGIBILITY

Eligibility & Benefits Verification

Instant access to patient copay, deductibles, and out-of-pocket costs. Calculates Patient Financial Responsibility to provide an accurate cost estimate.

INSURANCE A · PRIMARY

LIVE

Co-Pay

$40

Co-Insurance

20%

Deductible Remaining

$188

Patient Responsibility

$228

STEP 01 / ELIGIBILITY

Eligibility & Benefits Verification

Instant access to patient copay, deductibles, and out-of-pocket costs. Calculates Patient Financial Responsibility to provide an accurate cost estimate.

PAYER RULE CHECK

UHC · ONC POLICY v2024.3

Authorization required

for J9263 · Oxaliplatin

Auth on file

· 3 visits remaining

No prior denial

on record · clear to submit

STEP 01 / ELIGIBILITY

Eligibility & Benefits Verification

Instant access to patient copay, deductibles, and out-of-pocket costs. Calculates Patient Financial Responsibility to provide an accurate cost estimate.

INSURANCE A · PRIMARY

LIVE

Co-Pay

$40

Co-Insurance

20%

Deductible Remaining

$188

Patient Responsibility

$228

STEP 02 / VERIFICATION

Authorization Verification

Checks if authorization is needed through payer guidelines. In cases of authorization on file, reads prior approvals and denial letters, and evaluates visit counts for accurate next-DOS evaluation.

PAYER RULE CHECK

UHC · ONC POLICY v2024.3

Authorization required

for J9263 · Oxaliplatin

Auth on file

· 3 visits remaining

No prior denial

on record · clear to submit

STEP 03 / MEDICAL NECESSITY

Medical Necessity Assessment & Recommendation

Leverages evidence-based and payer guidelines to create automated checklists, assessing each item to provide clear approval or denial recommendations.

REGIMEN: FOLFOX · ICD-10 C50.912

CRITERIA 4/5

One of the following criteria should be met:

Combination therapy with fluorouracil-based chemotherapy regimens; OR

J0640: Injection, leucovorin calcium, 50mg

J9263: Injection, oxaliplatin, 0.5mg

●

CRITERIA MET · APPROVE RECOMMENDED

STEP 04 / SUBMISSION

Prior Authorization Submission

Auto-populates and submits PA forms with all required clinical documents and questionnaires.

PACKET — PATIENT 4821 · FOLFOX

21d AHEAD OF DOS

PA Form

· UHC standard

FILED

Clinical Notes

· 4 attached

FILED

ICD-10 + HCPCS

· C50.912 / J0640+

FILED

Questionnaire

· auto-populated

FILED

STEP 05 / TRACKING

Real-Time Status Tracking

Constant updates and real-time status tracking from payer portals, e-fax, and email — no portal logins required from your team.

CASE 4821 · ACTIVITY

UPDATED 2m AGO

Submitted via payer portal

Apr 22 · 09:14

Received by UHC

Apr 22 · 09:16

Under clinical review

now · ETA 24h

Determination

pending

STEP 06 / APPEALS · NEW

Automated Appeal Letters

Best-in-class appeal letters crafted by analyzing research and medical necessity guidelines — drawing directly on the payer's own policy language.

APPROVED APPEAL LETTER

23 CITATIONS

The patient's diagnosis

(ICD-10: C34.90, Malignant Neoplasm of the Lung)

is a covered condition per the Oncology Benefits policy. The requested regimen aligns with NCCN guidelines for the stated line of therapy and satisfies medical necessity criteria on file.

— OneRISA, Medical Necessity Appeals Engine

Workflow

Delivering speed, accuracy, and efficiency across every step.

STEP 01 / ELIGIBILITY

Eligibility & Benefits Verification

Instant access to patient copay, deductibles, and out-of-pocket costs. Calculates Patient Financial Responsibility to provide an accurate cost estimate.

INSURANCE A · PRIMARY

LIVE

Co-Pay

$40

Co-Insurance

20%

Deductible Remaining

$188

Patient Responsibility

$228

STEP 02 / VERIFICATION

Authorization Verification

Checks if authorization is needed through payer guidelines. In cases of authorization on file, reads prior approvals and denial letters, and evaluates visit counts for accurate next-DOS evaluation.

PAYER RULE CHECK

UHC · ONC POLICY v2024.3

Authorization required

for J9263 · Oxaliplatin

Auth on file

· 3 visits remaining

No prior denial

on record · clear to submit

STEP 03 / MEDICAL NECESSITY

Medical Necessity Assessment & Recommendation

Leverages evidence-based and payer guidelines to create automated checklists, assessing each item to provide clear approval or denial recommendations.

REGIMEN: FOLFOX · ICD-10 C50.912

CRITERIA 4/5

One of the following criteria should be met:

Combination therapy with fluorouracil-based chemotherapy regimens; OR

J0640: Injection, leucovorin calcium, 50mg

J9263: Injection, oxaliplatin, 0.5mg

●

CRITERIA MET · APPROVE RECOMMENDED

STEP 04 / SUBMISSION

Prior Authorization Submission

Auto-populates and submits PA forms with all required clinical documents and questionnaires.

PACKET — PATIENT 4821 · FOLFOX

21d AHEAD OF DOS

PA Form

· UHC standard

FILED

Clinical Notes

· 4 attached

FILED

ICD-10 + HCPCS

· C50.912 / J0640+

FILED

Questionnaire

· auto-populated

FILED

STEP 05 / TRACKING

Real-Time Status Tracking

Constant updates and real-time status tracking from payer portals, e-fax, and email — no portal logins required from your team.

CASE 4821 · ACTIVITY

UPDATED 2m AGO

Submitted via payer portal

Apr 22 · 09:14

Received by UHC

Apr 22 · 09:16

Under clinical review

now · ETA 24h

Determination

pending

STEP 06 / APPEALS · NEW

Automated Appeal Letters

Best-in-class appeal letters crafted by analyzing research and medical necessity guidelines — drawing directly on the payer's own policy language.

APPROVED APPEAL LETTER

23 CITATIONS

The patient's diagnosis

(ICD-10: C34.90, Malignant Neoplasm of the Lung)

is a covered condition per the Oncology Benefits policy. The requested regimen aligns with NCCN guidelines for the stated line of therapy and satisfies medical necessity criteria on file.

— OneRISA, Medical Necessity Appeals Engine

Part B Auths.Part D Auths.One Platform.OneRISA

Delivering speed, accuracy, and efficiency across every step.

Delivering speed, accuracy, and efficiency across every step.

Delivering speed, accuracy, and efficiency across every step.

Part B Auths.
Part D Auths.
One Platform.
OneRISA