Prior Authorization Agent
An agentic AI worker that takes prior authorization requests from intake to recommendation — extracting clinical evidence, checking it against medical policy and routing only the cases that need a clinician.
Faster Decisions · Fewer Denials · Lower Cost
Prior authorization was built to control cost. It now creates it.
Requests arrive by fax, portal, phone and API. Staff re-key clinical information, nurses wait on missing documentation and decisions stall in queues — delaying care and increasing compliance exposure as timelines tighten.
Manual intake
Requests across fax, phone and portals are routed and re-keyed by hand, introducing delay and errors.
Missing documentation
Incomplete submissions trigger back-and-forth with providers that adds days to every case.
Tightening timelines
Regulatory decision and notification timelines leave little room for queue-based review.
What the Prior Authorization Agent does
Purpose-built skills that work together to complete the workflow end to end.
Omnichannel intake
Captures requests from fax, portal, email and API and extracts member, provider, service and diagnosis details.
Clinical evidence extraction
Reads attached clinical notes and records to find the evidence relevant to the requested service.
Policy & criteria matching
Compares evidence against medical policy and coverage criteria, citing exactly what was met or missing.
Gap detection
Flags missing information early and drafts the request back to the provider.
Smart triage & routing
Prioritizes urgent cases and routes complex ones to the right nurse or physician reviewer.
Status & notifications
Keeps providers and members updated and prepares determination letters for approval.
From request to result in four steps
Intake
Request received and structured from any channel.
Evidence
Clinical documentation extracted and summarized.
Criteria
Evidence matched to policy with a cited recommendation.
Decision
Clinician approves, adjusts or escalates; agent notifies.
Autonomous where it's safe. Accountable everywhere.
The agent recommends; licensed clinicians decide. Adverse determinations are never automated — they are always routed to a qualified reviewer with the evidence summary attached.
Built-in guardrails
- Configurable auto-approval only for criteria-met, low-risk requests
- All potential denials routed to clinical review
- Evidence citations attached to every recommendation
- Complete audit log for regulatory and appeals review
Works with the systems you already run
Secure connectors and APIs let the agent act inside your existing platforms — no rip-and-replace.
What changes for your team
Faster turnaround
Routine requests move from intake to recommendation without waiting in a queue.
Clinicians on clinical work
Reviewers spend their time on complex cases, not data entry.
Stronger compliance
Consistent criteria application and timeline tracking on every case.
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Learn moreSee the Prior Authorization Agent in action
Book a demo with our team to see how the agent fits your workflows, systems and governance requirements.