SilicoHealth AI · Prior Auth Platform
Prior authorization and utilization management were designed as cost-control mechanisms. Instead, they have become the single biggest source of friction in the healthcare system. Manual workflows, siloed data, and rule-based automation have pushed payers to a breaking point one where operational costs are rising even as outcomes stagnate.
1
Administrative Overload
Payer staff spend 60–70% of their time on administrative tasks that add no clinical value. Every PA request demands manual data entry, phone calls, and redundant documentation across disconnected systems.
2
Clinical Friction
Physicians lose an average of 2+ hours per day to PA tasks. Delays in authorization directly delay care with downstream impacts on readmissions, member satisfaction, and quality scores.
3
Compliance Exposure
CMS and state regulators are tightening PA timelines and denial standards. Manual processes cannot keep pace with evolving requirements, creating audit risk and liability exposure for plans.
AI Architecture
A Unified Platform Built for Payer Operations
Most payers today manage prior authorization through a sequence of disconnected steps each handled by a different team, system, or vendor. GovernAI replaces this fragmented chain with an end-to-end agentic AI system that learns, adapts, and acts in real time.
Fax / Phone Submission
Provider submits via fax; staff manually routes requests.
Manual Data Entry
Staff re-keys clinical info into PA system — error-prone & slow.
Nurse Review Queue
Requests queue for nurse review; average 2–3 day wait.
MD Peer Review
Complex cases escalate to physicians; bottleneck adds 2–5 days.
Manual Notification
Staff manually sends letters; no real-time status updates.
Omnichannel AI Intake
Portal, fax, API & phone requests auto-extracted instantly.
AI Agent Intake & Triage
AI classifies, prioritizes and routes requests in seconds.
Real-Time Clinical AI Review
NLP-driven guideline matching and automated approvals.
Auto-Determination or Escalation
Routine cases approved automatically; complex cases escalated.
Instant Multi-Channel Notification
Real-time status updates via portal, EHR and member app.
Agentic AI Architecture
A Unified Platform Built for Payer Operations
GovernAI’s architecture is purpose-built for the complexity of payer operations combining a secure data platform, multi-agent AI orchestration, and clinical intelligence into one integrated system.
Step-by-Step Workflow
Before & After: The Prior Auth Transformation
See exactly how each step in the prior authorization process transforms when GovernAI’s agentic AI system takes over from manual operations.
Provider Submits Fax
Manual input
Error ProneStaff Manual Entry
Re-keying data
SlowNurse Review Queue
Queue: 2–3 days
BacklogMD Review 2–5 Days
Bottleneck
DelayedManual Notification
Letters & Calls
No VisibilityOmnichannel Request
Any channel
InstantAI Agent Intake
Auto-extracted
<60 SecsReal-Time Clinical AI
Guideline match
<1 Min AIAuto-Determination
70%+ Auto-approved
InstantInstant Notification
Portal + EHR Push
Real-Time| Metric | Before: Manual PA | After: Agentic AI | Improvement |
|---|---|---|---|
| PA Turnaround Time | 3–14 Days | < 4 Hours | -90% |
| Auto-Approval Rate | < 15% | > 70% | +55pp |
| Staff Hours per 100 PAs | 120+ Hours | < 30 Hours | -75% |
| Denial Rate | 40%+ | < 12% | -28pp |
| Appeals Resolved < 7 Days | 35% | > 85% | +50pp |
| Regulatory Audit Readiness | Manual Docs | Auto-Generated | 100% |
Platform Capabilities
What GovernAI Delivers for Prior Auth & UM
AI-Powered PA Intake
Any-channel request submission (portal, fax, phone, API) with AI-driven data extraction and auto-population eliminating manual entry and reducing intake errors by >80%.
Bias & Fairness Auditing
Demographic parity, equalized odds, and calibration with healthcare-specific fairness benchmarks calibrated to known disparities.
Autonomous Determination Engine
Agentic AI systems handle routine authorization decisions without human touch applying learned patterns from millions of prior decisions to achieve 70%+ straight-through processing.
Utilization Management Intelligence
Prospective, concurrent, and retrospective UM workflows powered by AI-driven risk stratification, care pathway optimization, and predictive analytics for high-cost member identification.
Compliance & Audit Automation
Auto-generated audit documentation, CMS-compliant turnaround time tracking, denial letter generation, and real-time regulatory dashboard for state and federal reporting.
Appeals & Grievance Management
AI-assisted appeals intake, evidence gathering, and resolution reducing appeals processing time by 60% and improving first-level resolution rates to exceed regulatory thresholds.
The GovernAI Architecture
A 4-Layer Governance Framework
GovernAI maps every regulation, standard, and accreditation requirement into a single unified compliance architecture so your team governs once, not four times.
Pillar 01
Intake & Triage Intelligence
Agentic AI systems handle intake, triage, and clinical review documentation across all channels with real-time NLP extraction, structured output, and smart routing to the right workflow.
Pillar 02
AI-Driven Risk Stratification
AI-driven risk stratification uses member history, diagnosis codes, and treatment patterns to predict authorization outcomes, flag high-risk cases, and optimize clinical resource allocation
Pillar 03
Compliance & Transparency
Agentic AI systems track every determination, generate explainable audit trails, and produce regulatory-ready documentation ensuring full compliance with CMS, NCQA, and state mandates at all times.