Accelerate prior authorizations with AI-assisted reviews and integrity checks
Clinical Scope accelerates emergent decisions and helps clinical teams and medical directors process authorization requests faster with an AI-assisted solution.
Our AI-assisted claims integrity solution is popular with pre-authorization Clinical Teams and Medical Directors at major healthcare companies and agencies in North America. It includes:
AI analyzes all authorization requests
and correlates them with recent provider and claims data, to give you insights into the recent behavior of the provider, facility, pharmacy and member involved.
Pre-auth analysis flags problematic requests
and gives clinical teams unique insights that inform the best next steps.
AI-based Prior-Auth Scores
can be incorporated into your authorization approval process. Prior Auth Scores flag authorization requests that fail to follow normal clinical care standards. Clinical Scope provides detailed explanations for each Auth Request Risk score.
Green light low risk authorizations for gold carded providers.
Pause authorization requests
from providers associated with current FWA schemes or from providers flagged by the Codoxo Community.
Accelerate pre-auth reviews
and ensure every referral is to a legitimate physician with an auto-approval rules engine that can be customized and fine-tuned by each client over time.
gives clinical teams one place to quickly review all pre-auth request details, and built-in workflow to approve, pend or send medical document requests for further analysis.
Prior auth compliance dashboard and rich reporting
on claims, providers and authorization requests makes it easy for anyone to search, filter and view similar requests for this member – without any help from IT.
can send automated requests for more information to providers with a history of problematic claims and also integrate back into your core claims systems.
Reduce professional abrasion
and ensure professionals with high Provider Integrity Scores get fast authorizations for their patients.
all claim types
Codoxo can ingest and analyze all professional, facility, pharmaceutical, behavioral, dental, and workers comp claims.
Our patented AI technology has the ability to identify issues and opportunities that may arise from complex claims and codes in addition to the standard ones which helps discover a wider range of existing and emerging problems.
Clinical Scope is built on our Forensic AI Platform and a part of the Codoxo Healthcare Integrity Suite
Our AI engine analyzes your claims data, detects practices that intentionally or unintentionally waste money, and builds connections across your data to provide actionable insights.
Saving millions at world-class insurance companies and healthcare agencies including:
State Medicaid Agency
2+ million recipients
Southeast Blue Plan
3+ million members
Midwest Blue Plan
2.9 million members
Pacific Health Plan
"Codoxo's Forensic AI Platform is a game changer.
– Kurt Spear, Vice President Financial Investigations and Provider Review
Ready to get started?
Talk with a sales rep to get a demo of Codoxo and learn more.