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Clinical
WF-01
Patient Scheduling & Follow-Up
- 1Intake screening: Collect chief complaint, insurance ID, and referring provider during initial contact; document in EMR before scheduling.
- 2Eligibility pre-check: Run real-time eligibility verification via payer portal or clearinghouse to confirm active coverage and applicable co-pay before booking.
- 3Appointment entry: Book appointment in EMR scheduler with correct visit type, provider, and care team; attach referral or order documents as required.
- 4Automated reminders: Trigger 72-hr and 24-hr patient reminders via SMS/email; log outreach in EMR communication tab to maintain audit trail.
- 5No-show protocol: For unconfirmed or missed appointments, execute same-day outreach and document reschedule attempts per clinic policy.
- 6Wait-list management: Maintain cancellation wait-list in EMR; fill open slots within 2 hours to maximize provider utilization.
- 7Post-visit follow-up: Schedule follow-up appointments per provider discharge instructions and flag outstanding referrals or orders in EMR task queue.
Outcome: Reduces no-show rate, maximizes provider schedule density, and ensures continuity of care documentation from first contact to follow-up.
EMR SchedulingEligibility Pre-checkHIPAANo-show Protocol
WF-02
Prior Authorization
- 1Order review: Identify procedures or medications requiring prior authorization by cross-referencing the provider's order with the payer's pre-auth requirement list.
- 2Clinical documentation pull: Retrieve supporting clinical notes, diagnosis codes (ICD-10), procedure codes (CPT/HCPCS), and relevant labs or imaging from EMR.
- 3Medical necessity criteria: Verify that documentation satisfies the payer's medical necessity guidelines (e.g., InterQual, MCG); flag gaps and request addendum from provider if needed.
- 4Payer portal submission: Submit PA request via payer portal or fax with complete clinical package; record reference number and expected turnaround in EMR authorization tracker.
- 5Status follow-up: Check authorization status at 48-hr intervals; escalate pending requests exceeding payer SLA to the provider or authorization specialist.
- 6Approval/denial documentation: Log approval number, valid dates, and approved units in EMR; attach denial letters and initiate appeal process within payer's appeal window.
- 7Provider & patient notification: Communicate approval status to clinical team; notify patient of any cost-share implications or scheduling next steps.
Outcome: Prevents claim denials due to missing authorizations, reduces treatment delays, and maintains a complete authorization audit trail for billing compliance.
Payer PortalICD-10 / CPTMedical NecessityAppeal Process
WF-03
Insurance Eligibility Verification
- 1Daily verification queue: Generate a list of appointments scheduled within the next 3–5 business days and add all patients to the eligibility verification queue.
- 2Real-time eligibility check: Run 270/271 eligibility transactions via clearinghouse (Availity, Change Healthcare) or directly through the payer portal; capture active coverage and effective dates.
- 3Benefits breakdown: Document deductible, out-of-pocket maximum, co-pay, co-insurance, and in-network/out-of-network status for the relevant specialty and visit type.
- 4Secondary coverage check: Confirm coordination of benefits (COB) for patients with dual coverage; document primary and secondary payer order in EMR.
- 5Discrepancy resolution: Flag terminated or mismatched coverage to the front desk and patient; collect updated insurance information and re-verify before the appointment date.
- 6EMR update: Post verified benefits to the patient's insurance tab in the EMR; include effective date, group/member ID, and verification reference number.
- 7Pre-visit financial communication: Notify patients of estimated co-pay or outstanding balance prior to visit to reduce day-of collection issues.
Outcome: Eliminates eligibility-related claim rejections, improves point-of-service collections, and reduces accounts receivable aging from coverage errors.
270/271 EDIAvaility / Payer PortalCOBAR Management
WF-04
Prescription Refill Management
- 1Refill request intake: Receive electronic refill requests from pharmacy (SureScripts), patient portal, or phone; log all requests in the EMR refill task queue with timestamp and source.
- 2Chart review: Verify last office visit date, active problem list, current medication list, and any labs required before renewal.
- 3Eligibility & formulary check: Confirm medication is covered under patient's current plan formulary; identify generic alternatives or preferred tier options to reduce patient cost.
- 4PA flagging: Identify medications requiring prior authorization before refill; initiate PA workflow concurrently to prevent treatment gaps.
- 5Provider routing: Route refill request to the appropriate provider via EMR inbox with a pre-populated summary (last visit, labs, indication) to expedite review and e-prescribing.
- 6eRx transmission: Upon provider approval, confirm electronic prescription (eRx) was transmitted to the patient's preferred pharmacy; document approval in EMR.
- 7Patient notification: Notify the patient of refill status (approved, pending, or denied with alternative) and estimated pharmacy fill time.
Outcome: Eliminates medication gaps, reduces provider inbox burden, ensures formulary compliance, and supports patient medication adherence.
SureScripts eRxFormulary CheckPrior AuthMedication Reconciliation
WF-05
Inbox & Task Management
- 1Daily inbox review: Process provider and staff EMR inboxes at scheduled intervals (morning, midday, end-of-day); clear actionable items within defined SLA windows.
- 2Task triage: Categorize tasks by urgency (urgent, routine, informational) and type (clinical, administrative, billing, scheduling) using EMR task management tools.
- 3Delegation & routing: Assign non-clinical tasks to appropriate team members; route clinical tasks to the covering provider with relevant patient context attached.
- 4Patient portal messages: Respond to patient messages within 24–48 hours per clinic policy; escalate clinical questions to provider; document all responses in the patient's communication log.
- 5Document processing: Index incoming faxes (referrals, records, lab results) to the correct patient chart; attach to the relevant encounter and flag provider for review.
- 6Escalation protocol: Immediately escalate urgent clinical communications (critical labs, abnormal imaging) to the on-call provider with no delay.
- 7End-of-day reconciliation: Confirm all open tasks have an owner and due date; carry forward unresolved items and brief the next available team member.
Outcome: Reduces provider administrative burden, ensures zero task drop-off, and supports regulatory compliance by maintaining a full communication audit trail.
EMR InboxTask DelegationPatient PortalDocument Indexing
WF-06
Lab Results Handling
- 1Result receipt: Receive lab results via HL7 interface, fax, or lab portal; confirm automatic posting to the correct patient's EMR chart by matching MRN, DOB, and order number.
- 2Critical value flagging: Identify critical or panic values per lab reference ranges; immediately notify the ordering or covering provider via phone with read-back confirmation and document in EMR.
- 3Provider routing: Route all results to the ordering provider's EMR inbox with a summary notation; flag results requiring action with a priority label.
- 4Pending result follow-up: Track outstanding lab orders; follow up with the lab on results exceeding expected turnaround time to prevent delayed diagnosis.
- 5Patient notification: Communicate results to the patient per provider's instructions (normal via portal; abnormal via phone call) within the clinic's defined timeframe policy.
- 6Follow-up scheduling: Schedule follow-up visit or additional testing as directed by the provider's result review; link order to the original lab result in the EMR encounter.
- 7Documentation close-out: Confirm all results have been reviewed and acknowledged by the provider in the EMR; close result tasks and log patient notification in the communication record.
Outcome: Eliminates missed or delayed results, supports timely clinical decision-making, and reduces liability from unreported critical lab values.
HL7 InterfaceCritical Value ProtocolEMR Result RoutingTurnaround Tracking
Administrative & Operations
WF-07
Business Call Handling
- 1Professional greeting & screening: Answer calls using clinic-standard greeting; identify caller type (payer, vendor, referral source, or business partner) and purpose before proceeding.
- 2Call classification: Categorize inbound calls as urgent, routine, or informational; apply appropriate SLA (urgent within 1 hour, routine within 1 business day).
- 3Information verification: For payer or referral calls, verify caller identity (NPI, TIN, or provider credentials) before disclosing any practice or provider-specific information.
- 4Real-time documentation: Log call summary, caller contact information, issue details, and requested action in the practice management system or CRM immediately during the call.
- 5Routing & warm transfer: Route calls requiring clinical staff or provider involvement with a full context summary; avoid cold transfers that require callers to repeat information.
- 6Message relay: Deliver accurate voicemail or call-back messages to the appropriate team member within defined relay timeframes; confirm receipt.
- 7Follow-up & close: If action was promised, initiate follow-up within the committed timeframe; update call log with resolution status and close the task in the practice management system.
Outcome: Ensures every business contact is handled professionally, routed efficiently, and documented thoroughly — protecting the practice from miscommunication and missed escalations.
Call TriageCRM LoggingPayer CommunicationSLA Compliance
WF-08
Business Email & Inbox Management
- 1Inbox sweep (3× daily): Review shared and provider-specific business inboxes at defined intervals; apply folder structure (Action Required, Awaiting Reply, Reference, Archive).
- 2Triage & prioritization: Flag time-sensitive emails (payer correspondence, authorization notices, contract documents) for same-day response; defer non-urgent items with a follow-up reminder set.
- 3Response drafting: Compose accurate, professional email responses using clinic-approved templates; ensure all outgoing emails adhere to HIPAA minimum necessary standards before sending.
- 4Provider review queue: Route emails requiring provider approval or signature to a dedicated review folder; summarize context in the subject line to reduce provider reading time.
- 5Attachment handling: Save and label incoming documents (EOBs, contracts, referral letters) to shared drive using standardized naming convention; link document to relevant EMR or practice record.
- 6Thread tracking: Maintain running tracking log for multi-party email threads (payer negotiations, vendor agreements); flag threads idle over 48 hours for follow-up.
- 7Archive & compliance: Archive resolved threads per practice email retention policy; ensure PHI is never transmitted via unsecured email; use encrypted portal for any patient-related business correspondence.
Outcome: Maintains organized, responsive, and HIPAA-compliant communication channels that support provider efficiency and reduce risk from missed or misrouted correspondence.
Inbox Zero ProtocolHIPAA Email PolicyEOB ProcessingEncrypted Communication
WF-09
Basic Marketing & Outreach Support
- 1Content calendar setup: Build and maintain a monthly content calendar aligned with clinic priorities (new services, seasonal health campaigns, provider spotlights); present to practice manager for approval.
- 2Draft creation: Write HIPAA-compliant social media posts, email newsletters, and patient education content; ensure no PHI or identifiable patient data appears in any public-facing material.
- 3Provider & compliance review: Route all outbound content through the clinic's designated approver (physician champion or compliance officer) before publication.
- 4Scheduling & publishing: Schedule approved posts using the clinic's social media management tool; coordinate timing with clinic hours, campaigns, and community health events.
- 5Patient recall outreach: Execute targeted outreach for overdue preventive care (annual physicals, mammograms, colonoscopies) using EMR population health tools; document outreach in patient record.
- 6Review management: Monitor Google and Healthgrades reviews; route negative feedback to practice manager per clinic escalation policy; draft provider-approved responses to positive reviews.
- 7Performance reporting: Compile monthly engagement report (reach, appointment conversions, new patient inquiries) and present summary to practice leadership.
Outcome: Supports patient acquisition and retention, strengthens clinic online reputation, and drives preventive care utilization — all within HIPAA marketing compliance guidelines.
HIPAA-Compliant ContentPatient RecallReputation ManagementPopulation Health
WF-10
Vendor & Partner Coordination
- 1Request intake: Receive supply, service, or equipment requests from clinical and administrative staff; log in the vendor management tracker with requestor, priority level, and budget category.
- 2Vendor outreach: Contact approved vendor(s) for quotes or service scheduling; maintain a prequalified vendor list approved by the practice administrator to streamline procurement.
- 3Quote comparison & approval routing: Compile and compare quotes for purchases above defined threshold; present cost-benefit summary to the practice administrator for purchase order (PO) authorization.
- 4BAA verification: Confirm Business Associate Agreement (BAA) is executed and current for any vendor with potential access to PHI (IT vendors, EHR support, shredding services, billing companies).
- 5Order & delivery tracking: Issue POs or confirm service appointments; track delivery or completion against confirmed timelines; escalate delays that impact clinic operations.
- 6Invoice processing: Receive and match invoices against POs and delivery confirmations (3-way match); route discrepancies to the practice administrator before approving for payment.
- 7Vendor performance log: Maintain a running vendor performance record (on-time delivery, quality issues, contract renewals); flag underperforming vendors for administrator review at quarterly intervals.
Outcome: Ensures uninterrupted clinic supply chain, maintains HIPAA vendor compliance through BAA oversight, and supports cost control through structured procurement and invoice reconciliation.
BAA CompliancePurchase Order3-Way MatchVendor Management