Manage provider requests

Trigger: A healthcare provider submits an inquiry, authorization request, or administrative appeal through a portal, call center, or electronic data interchange.

1. Ingest provider request and capture initial data
2. Authenticate provider identity and active network status
3. Triage and route the request to the appropriate administrative or clinical queue
4. Cross-reference the request with member benefits, claim history, and medical policies
5. Adjudicate the request to formulate a definitive decision
6. Transmit the resolution and updated status back to the provider

Outcome: The insurance carrier reviews the submission, finalizes a decision or answer, communicates the resolution to the provider, and logs the interaction in the core system.