White Paper
Solving SB 306 Compliance with Auditable PA-to-Claims Matching
California SB 306 changes prior authorization (PA) from a clinical oversight task into a complex data governance challenge. Plans must now prove the value of their PA protocols at the service-code level. However, most payers operate on legacy architectures where Utilization Management (UM) and Claims Adjudication exist in silos, making it difficult to demonstrate the required lineage between an authorization request and the eventual care delivered.
This white paper examines the specific data lineage requirements of SB 306 and introduces Gaine’s PA to Claims Matching Service. This solution provides an auditable, service-based architecture that enables health plans to create regulator-defensible datasets without necessitating large-scale capital expenditure on internal infrastructure.
The risks of relying on disjointed data or manual spreadsheets for SB 306 reporting are significant. Download the white paper to discover:
- The "Delegation Dilemma": How to attribute utilization accurately when delegates (IPAs/MSOs) make the PA decisions but the plan processes the claims.
- Resolving Service Code Drift: Strategies for linking records when the code used for a PA request differs from the specific CPT code on the final claim.
- Managing Temporal Mismatches: How to account for the lag time in Durable Medical Equipment (DME) or complex behavioral health episodes without creating false positives.
- Why Standard Matching Fails: The specific failure modes of simple date-based or member-ID joins that lead to under-reporting approved utilization.
- The Gaine Approach: How the PA to Claims Matching Service normalizes data from disparate sources to produce a linked, auditable record set.
- Operational ROI: The benefits of a shared service model that integrates with your existing Snowflake environment versus building custom matching algorithms internally.