NaviNet for Payers
Real-time prior authorizations across your provider network
NaviNet® Prior Authorizations gives your network a real-time, multi-payer authorization channel, replacing the fax queues and call volume that drive provider abrasion, regulatory exposure, and operating cost on your side of the relationship.
Prior auth is the most expensive transaction in your operation, and the loudest source of provider abrasion
Manual auth workflows drive call volume into your contact center, slow down regulatory turnaround, and erode the network relationships you depend on. Every faxed form is a touchpoint that doesn’t have to happen.
Manual prior auth workflows
- Authorization forms arrive by fax, phone, and mail, with the staffing cost to match
- High call volume into your UM and contact center teams
- Submissions flow in for services that didn’t require auth in the first place
- Status inquiries handled by phone, one provider call at a time
- Provider frustration damages network relations and Star ratings
Real-time, multi-payer auth channel
- Real-time submission and inquiry across your contracted providers
- Plan-specific business rules applied at submission, before queue
- Behind-the-scenes E&B check filters out unnecessary auth requests
- Status updates and RFMI delivered without inbound calls
- Streamlined provider experience strengthens network relations
$16.29 per manual auth. 14 minutes per request. 65% still on paper.
The CAQH Index quantifies the cost gap between manual and electronic prior authorizations. Authorizations remain one of the lowest-digitized transactions in healthcare, and one of the highest-cost on the payer side.
- $16.29
Industry cost of a single manual prior authorization transaction.1
- 35%
Share of authorization transactions that are fully electronic today, the rest still move by fax, phone, or mail.1
- 14 min
Average time saved per authorization by moving from manual to electronic workflows.1
- Real-time
Submission, inquiry, and status updates happen inside NaviNet, no call center detour, no fax queue.
From provider submission to determination, in one configurable workflow
Built for the way your plan actually runs prior auth
Configurable to your business rules. Embedded in the workflow your contracted providers already use. Designed to reduce provider friction and your team’s manual workload at the same time.
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Multi-payer Submission Channel
Real-time, HIPAA-compliant authorization submission and inquiry across your network, through the NaviNet portal your providers already use for eligibility and claims.
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Eligibility Pre-check
A behind-the-scenes eligibility and benefits inquiry confirms member status and whether an authorization is actually required, filtering out unnecessary submissions before they hit your queue.
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Configurable Business Logic
Auto-approval rules, duplicate detection, and plan-specific validation applied at submission, configured to match your medical policy and benefit design.
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Attachments & Questionnaires
Collect the clinical documentation your UM team needs upfront through attachments and customizable questionnaires, reducing back-and-forth and request-for-more-information cycles.
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Auth Log & Search
One log, one view, every contracted provider. Flexible search across patient, provider, plan, and status, for both your team and the network you serve.
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Amendments & Appeals
Support amendments and appeals from the same workflow, governed by your plan’s business rules.
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Status Updates & Notifications
Push RFMI, status changes, and determinations back to providers automatically, eliminating the inbound calls that drive your contact center volume.
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Third-party Integrations
Surface third-party clinical decision support and UM tools at key points in the workflow, without sending providers to a separate portal.
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Regulatory Turnaround Support
Real-time channel and structured audit trail help you hit CMS and state Medicaid turnaround time requirements with documentation to back it up.
What real-time prior auth unlocks for your plan
- Lower per-transaction cost on one of your highest-volume admin transactions
- Reduced inbound call volume into your UM and contact center teams
- Stronger provider satisfaction, a Star ratings and CAHPS input you can directly influence
- Fewer unnecessary auth submissions via behind-the-scenes E&B checks
- Better positioning for CMS and state Medicaid TAT requirements
- Cleaner audit trail for regulatory and accreditation review
- Streamlined network experience without standing up a new portal
- Accommodates your existing medical policy and business rules, not a generic workflow
Integration essentials
- Real-Time EDI Gateway Web Service
- CAQH/CORE Open Authorization Connectivity and Data Content Operating Rules
- Secure HTTPS with TLS 1.2+
- Delivery of a Vendor (Entity) and Provider Data Feed
- 278 Health Care Services Review, Inquiry and Response
- 278 Request for Review and Response
- Plan-specific search criteria, default data values, and EDI parameters
- HITRUST CSF certified
- NCQA accredited health utilization management
- CAQH CORE certified
- HIPAA-compliant end-to-end encryption
Common questions about NaviNet Prior Authorizations
How is this different from standing up our own provider portal?
A proprietary portal asks every contracted provider to learn one more login, on top of every other plan they touch. NaviNet is the multi-payer portal those provider offices already use. Adding Prior Authorizations through NaviNet means your business rules in a workflow they already know, which dramatically improves adoption versus a one-off portal build.
What types of authorizations does NaviNet handle?
NaviNet Prior Authorizations supports medical benefit prior authorization workflows, including service authorizations, requests for review, amendments, and appeals. Submission requests and inquiries flow through the 278 transaction set in real time. We can walk through your specific service-type and line-of-business coverage during a discovery call.
How configurable is the business logic to our plan’s medical policy?
Highly. Auto-approval rules, duplicate detection, plan-specific validation, RFMI behavior, and the “auth not required” check are all configurable to match your medical policy, benefit design, and line of business. Configuration happens during implementation; ongoing changes are supported through standard plan operations channels.
How does this help with CMS and state Medicaid turnaround time requirements?
Two ways. First, real-time channel + auto-approval rules dramatically reduce the share of auths that need touch from your UM team, which compresses turnaround. Second, every transaction lands with a structured audit trail, helpful both for hitting TAT and for documenting it during regulatory review.
What’s involved in implementation on our side?
The provider-facing portal is already in place, you don’t need to deploy software to your network. On your side, implementation centers on integration to your UM platform via the 278 transaction set, business rules configuration, and provider data feeds. Specifics depend on your existing infrastructure; happy to walk through it on a call.