Referral & Prior Auth Gateway

The Referral & Prior Auth Gateway sits between your EHR and payers. It checks coverage for each referral or order, works out whether the payer needs prior authorization, assembles and submits the request electronically where the payer accepts it, and tracks every request to a decision. Each request stays visible to your team instead of waiting unnoticed in a fax tray, a payer portal or someone's inbox.

The problem it solves

Prior authorization is still largely manual. Staff check coverage in one place, look up payer rules in another, gather notes from the EHR, submit through a mix of portals, phone and fax, then chase status by hand. When a step is missed, the patient's appointment moves or the claim is denied after the service.

Who it’s for

• Referral coordinators and prior authorization specialists
• Patient-access and scheduling teams
• Revenue-cycle and denial-management leaders
• Clinic and department managers
• Clinicians and their staff, who supply documentation when asked

1. IntakeReferrals and orders arrive from your EHR into one worklist, by department and urgency.
2. Eligibility and benefitsCoverage is checked electronically and the response stored with the referral, so problems surface before scheduling.
3. AuthorizationPayer rules decide whether authorization is needed. Where it is, the request is assembled from the order and clinical documentation and submitted electronically where the payer supports it.
4. Follow-upPending, approved, denied and expiring authorizations are tracked, with requests for more information routed back to the right person and outcomes written back to the referral.

One worklist

Every referral and authorization in one place, sorted by urgency and appointment date.

Payer rules library

Which services need authorization from which payer and plan, maintained in one place with the date each rule was last reviewed.

Electronic eligibility

X12 270/271 coverage checks through your clearinghouse, stored with the referral.

Electronic submission

X12 278 through your clearinghouse, and payer prior authorization APIs where payers provide them.

Documentation packets

The order, notes and results the payer asks for, gathered from the EHR into one request.

Clinician requests

When documentation is missing, a specific request goes to the ordering clinician's team, not a general message.

Status tracking

Decisions, pends and expiry dates tracked, with reminders before an authorization lapses.

Authorization details

Authorization number, approved units, valid dates and site or provider restrictions recorded and checked against the appointment.

Denial follow-up

Denials routed with the payer's reason for peer-to-peer review or appeal, with the history kept together.

Portal hand-off

For payers without an electronic route, the request is prepared in full so a specialist can submit it on the payer's portal and record the result.

Write-back to the EHR

Status and outcomes written back to the referral, so scheduling and billing work from the same facts.

Audit trail

Every check, submission, response and change recorded with who did it and when.

Referral coordinator

Works the intake queue, checks coverage results and moves referrals to scheduling.

Prior authorization specialist

Builds and submits requests, answers payer questions and records decisions.

Clinician or clinical staff

Receives specific documentation requests and supplies notes or confirmation.

Patient-access lead

Resolves coverage problems and manages queues and assignments.

Revenue-cycle analyst

Reviews denials, expiring authorizations and reports by payer and service.

Administrator

Maintains payer rules, users, queues and interface settings.

EHR orders and referrals

Orders and referrals received through HL7 v2 or FHIR interfaces.

EHR documentation

Clinical notes and results retrieved for the request packet through FHIR or document interfaces.

EHR write-back

Status, authorization numbers and outcomes written back to the referral.

Clearinghouse

Eligibility and authorization transactions through the clearinghouse you already use.

Payer APIs

FHIR-based coverage requirements and prior authorization APIs following the HL7 Da Vinci guides, where payers offer them.

Scheduling

Appointment dates read from your scheduling system so work is sorted by when the patient is due.

Single sign-on

Staff sign in through your identity provider (SAML or OpenID Connect).

Work API

Worklist and outcome data available to your reporting and analytics tools through the Moraph Work API.

Business associate agreement

Moraph signs a business associate agreement covering the protected health information the Gateway processes.

Encryption and key control

Client data is encrypted, with keys Moraph staff cannot access without explicit, time-bound authorization, as described in our Trust Center.

Role-based access

Staff see the queues and records their role needs, and administrators control who has which role.

Minimum necessary

Request packets include the documents the payer's requirements call for, not the whole chart.

Audit logging

Every view, change, submission and export is logged with the user and time, and available for your compliance reviews.

Independent assurance

The Gateway runs within Moraph's SOC 2 Type II and ISO/IEC 27001 programs; reports are available under confidentiality terms through the Trust Center.

Moraph cloud

Hosted by Moraph in the United States region, under a business associate agreement.

Dedicated environment

Single-tenant hosting where your policies require it, scoped in the proposal.

Phased rollout

Can start with one department, service line or set of payers and expand under the same configuration.

With a managed service

Optionally paired with a Moraph managed service for interface monitoring and platform administration.

Payer and service inventory

Together we list the payers, plans and services that matter most to you, which sets the order in which rules are configured.

Payer rules setup

Authorization rules configured for your payers and services from published payer policies and your team's knowledge, and reviewed with your specialists.

EHR interfaces

Inbound orders, documentation retrieval and write-back built and tested with your EHR and integration teams.

Clearinghouse connection

Eligibility and 278 transactions enabled through your clearinghouse, including any enrollment the clearinghouse requires for each payer.

Queues and roles

Departments, queues, assignments and roles set up to match how your teams are organized.

Training and go-live

Coordinators, specialists and administrators trained on your configuration, and go-live planned by department or service line.

• Where a payer accepts requests only through its own portal, the Gateway prepares the request and a specialist submits it there.
• Medical-necessity documentation comes from your clinicians. The Gateway gathers it; it does not write it.
• Approval decisions are the payer's. The Gateway makes requests complete and visible, but cannot guarantee an outcome.
• Payer rules are configured with you during implementation and need to be kept current as payer policies change.
• Payer prior authorization APIs are only used where a payer offers one and the connection has been set up; availability varies by payer.
• Electronic eligibility and 278 transactions depend on your clearinghouse supporting them for each payer.
• It does not submit claims or post payments. It works alongside your billing system.
• Appeals are tracked and supported with the request history, but appeal letters are written by your staff.

• Bring a list of your highest-volume services and payers, and ask to see how the rules for them would be configured.
• Ask how a request for a payer with no electronic route is handled from start to finish.
• Ask to see a request for more information arrive and be routed to the right clinician.
• Check which of your clearinghouse's eligibility and 278 connections are available for your payers.
• Ask your EHR team which order, document and write-back interfaces are available, and review them with our engineers.
• Review the reports you would use for denials and expiring authorizations, and whether they match how you manage the work today.