Healthcare Prior Authorization Agent

A specialty practice submitting 50+ PA requests weekly dedicates 2 FTEs to the process. Each request: review clinical history, extract documentation supporting medical necessity, map to payer-specific criteria (which vary by payer and plan), prepare the package, submit, and track.

CMS mandates modernized PA by 2026 with electronic submission and faster responses. Cohere Health's Align streamlines approximately 80% of submissions for pre-approved providers. Abridge partnered with Availity for real-time PA at scale.

Average PA takes 30-45 minutes of staff time. Denials require hours of appeals. Delays in approval delay patient treatment — clinical and satisfaction impact.

The agent automates PA from trigger to resolution. When a provider orders a service requiring PA, it pulls relevant clinical documentation from the EHR: diagnoses, treatment history, labs, imaging, clinical notes establishing medical necessity.

Maps clinical evidence against payer-specific criteria. Different payers have different criteria for the same procedure. The agent maintains a payer criteria database matching your patient's clinical profile to the relevant criteria set. Where records support approval, it assembles the submission in required format.

For submissions that may not meet criteria: identifies the gap. "Payer requires documentation of failed conservative treatment — chart shows PT referral but no outcome documentation." Provider documents the missing information before submission rather than facing denial. Status tracking runs automatically; for denials, analyzes reason and prepares appeal targeting the specific denial basis.