Criteria Matched Before Submission — Not After the First Denial
Most PA denials are preventable documentation gaps. The agent flags every one before submission.
Award-Winning AI Prior Authorization Software
How Our AI Prior Authorization Agent Works
Physicians lose 14.6 hours a week to prior auth (AMA) — the agent reclaims it.
14.6 Hours of Weekly PA Burden Reclaimed for Patient Care
Automates criteria matching, packet drafting, and status tracking — physicians stay in the loop.
Denial Patterns Identified and Closed at the Root Cause
Denial analytics surface where a payer repeatedly blocks the same procedure — corrected upstream.
Key Features of the Prior Auth Automation Platform
Six capability pillars — from payer policy ingestion and criteria matching to packet drafting, submission, and denial management.
Continuously ingests MCG Health, InterQual, and payer-specific coverage criteria — keeping the library current without manual clinical review.
Retrieves the full patient record via FHIR R4 — notes, meds, labs, imaging, and prior PA outcomes for the patient-payer combination.
Generates the complete PA packet — justification letter with chart citations, ICD-10 and CPT codes, and a physician attestation ready for e-signature.
Submits via the optimal channel per payer — direct API through Availity, CoverMyMeds, and Surescripts, or portal automation where no API exists.
Every denial is auto-classified on receipt — medical necessity, step therapy, non-covered benefit, or documentation gap — before appeals begin.
Real-time dashboard of the active PA queue, approval and denial rates by payer, and average days to decision — full visibility into PA throughput.
Key Features of the Prior Auth Automation Platform
Six capability pillars — from payer policy ingestion and criteria matching to packet drafting, submission, and denial management.
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Payer Policy & Criteria Intelligence
Payer Policy & Criteria Intelligence
Continuously ingests MCG Health, InterQual, and payer-specific coverage criteria — keeping the library current without manual clinical review.
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Chart-to-Criteria Matching
Chart-to-Criteria Matching
Retrieves the full patient record via FHIR R4 — notes, meds, labs, imaging, and prior PA outcomes for the patient-payer combination.
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PA Packet Drafting & Justification
PA Packet Drafting & Justification
Generates the complete PA packet — justification letter with chart citations, ICD-10 and CPT codes, and a physician attestation ready for e-signature.
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Multi-Channel Submission & Tracking
Multi-Channel Submission & Tracking
Submits via the optimal channel per payer — direct API through Availity, CoverMyMeds, and Surescripts, or portal automation where no API exists.
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Denial Management & Appeals
Denial Management & Appeals
Every denial is auto-classified on receipt — medical necessity, step therapy, non-covered benefit, or documentation gap — before appeals begin.
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Revenue Cycle & PA Analytics
Revenue Cycle & PA Analytics
Real-time dashboard of the active PA queue, approval and denial rates by payer, and average days to decision — full visibility into PA throughput.
Every Manual PA Request Costs $11 in Staff Labour — Before Denied Revenue.
At 5,000 PAs/month, that's $540,000/year in labour — before denial and abandonment losses. The agent cuts manual handling time by 80% per request.
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Frequently Asked Questions
[ 1 ]
What is an AI Prior Authorization Agent and which PA types does it handle?
Manages the full PA lifecycle — criteria matching, packet drafting, submission, tracking, and appeals — for specialty medications, imaging, surgery, referrals, DME, and behavioural health.
[ 2 ]
How does the agent match patient chart data to payer clinical criteria without clinical staff involvement?
It pulls the full chart via FHIR R4 and uses clinical NLP to map each element against every payer criterion, producing a satisfied/partial/absent report with citations. Clinician review takes under 3 minutes.
[ 3 ]
What prevents the agent from hallucinating clinical justification content?
Every claim traces to a specific chart document, section, and date, and templates constrain output to retrieved data. The clinician reviews the packet with citations before submission.
[ 4 ]
Which EHR systems and payer submission channels does the agent integrate with?
EHR: Epic, Oracle Health/Cerner, athenahealth, NextGen, eClinicalWorks — or any FHIR R4 endpoint. Payers: Availity, CoverMyMeds, Surescripts, Cohere Health, and major payer APIs, plus portal automation. UAE: eClaimLink, Daman, Thiqa.
[ 5 ]
How does the denial management and appeals workflow operate?
The agent classifies the denial — medical necessity, step therapy, admin error, or documentation gap — drafts the appeal or peer-to-peer briefing, and routes it to the clinician with the deadline.
[ 6 ]
How does the agent handle payer policy changes and criteria updates?
Criteria are re-indexed daily or weekly per payer; updates refresh the matching model and flag affected in-progress PAs. A sharp approval-rate drop flags a probable undocumented policy change.
[ 7 ]
How does the system support urgent and expedited prior authorizations?
Expedited triggers come from urgency flags, diagnosis codes, or clinician designation. The agent applies the payer's expedited pathway (24–72h vs. 3–14 days) and escalates for immediate sign-off.
[ 8 ]
How long does implementation take and what ROI can we expect?
A focused deployment (one EHR, top 5 payers, top 20 PA types) runs 10–14 weeks. At 5,000 monthly PAs: $540K annual labour saving, 30–50% fewer initial denials, and payback in 5–8 months.
[ 9 ]
Does this prior authorization software support electronic prior authorization and the X12 278 prior authorization transaction?
Yes. It submits through the optimal channel per payer — Availity, CoverMyMeds, Surescripts, and Cohere Health APIs for electronic prior authorization, the X12 278 transaction where accepted, and portal automation elsewhere.
[ 10 ]
How does prior authorization automation reduce denials compared to manual processing?
Prior authorization automation matches chart data to payer criteria before submission, so gaps get fixed in minutes, not a multi-week appeal — and denial analytics surface systemic barriers.
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