Prior auth from clinical notes to payer submission, automated.
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.
We deploy a TypeScript/Node.js agent using Anthropic Claude to read and reason over clinical documentation pulled via HL7 FHIR APIs from your EHR. A structured criteria database — built for your top payers and procedure codes — drives the mapping logic, so the agent knows what each payer requires before submission. Submissions route to payer portals where electronic submission is supported; status polling runs on a Celery task queue backed by Redis. Setup takes 3-4 weeks including HIPAA BAA execution, EHR integration, and criteria database configuration.
Reads structured and unstructured data from your EHR via FHIR — diagnoses, labs, imaging reports, progress notes, and treatment history. Claude identifies and surfaces the documentation that supports medical necessity, flagging gaps before any submission is attempted.
Maintains a per-payer, per-procedure criteria database built from your actual payer mix. The agent maps extracted evidence to the correct criteria set and scores coverage confidence, so your team reviews exceptions rather than building every package from scratch.
Assembles PA packages in payer-required formats and submits electronically where portal APIs or clearinghouse connections are available. A polling layer tracks authorization status and triggers alerts on decisions, pending requests, and approaching deadlines.
When a denial comes back, the agent parses the denial reason code and maps it to the specific clinical or administrative gap cited. It then prepares targeted appeal documentation — pulling the relevant clinical evidence — rather than generating a generic resubmission.
Anonymized work with hard metrics — NDA-bound, no client names.
41%
Faster Critical Response
91%
Alert Precision
31%
False Alarm Reduction
“The false alarm rate was a genuine patient safety issue — staff were silencing monitors as a coping mechanism. The AI layer changed the signal-to-noise ratio enough that nurses are paying attention to alerts again.”
— ICU Clinical Director, Regional Medical Centre
We custom-build each agent to fit your data, your rules, and your existing systems.
Free 30-min scoping call
Fordel Studios