AI Prior Authorization
Reads the chart, matches it to payer criteria, and assembles a complete prior authorization packet, so clinical staff submit faster and see fewer denials without losing oversight.
Prior authorization buries clinical staff in payer-specific paperwork and stalls patient care, while denials from missing documentation force costly rework. We build prior authorization AI that reads the patient chart, matches it against the specific payer's criteria, and assembles a complete, evidence-linked submission packet. Every supporting fact cites the chart, and a clinician or auth specialist reviews before submission because medical necessity is a human call. The system runs inside your environment under HIPAA controls, so PHI stays protected while your team clears the queue faster and chases far fewer denials.
Pull the relevant chart data and the payer's prior authorization criteria for the request.
Match the clinical record against criteria and identify supporting evidence and gaps.
Assemble a complete packet where every justification cites the chart.
Route to a clinician or auth specialist to review and submit.
What it does
Criteria matching
Maps the chart to the exact payer and plan requirements for that request. Catches missing documentation before it becomes a denial.
Evidence-linked packets
Builds the submission with every justification cited back to the record. Reviewers verify in seconds instead of rebuilding the case.
Gap detection
Flags missing labs, notes, or prior treatments needed to meet criteria. Staff fix gaps up front rather than after a denial.
Clinician sign-off
Medical necessity decisions stay with a clinician or auth specialist. The AI prepares; your team approves and submits.
HIPAA-safe deployment
Runs in your environment with access controls and full audit logging. PHI never leaves your control.
Health systems cut time to prepare a prior auth by over 70 percent and reduce first-pass denials by roughly a third.
Questions, answered
No. It reads the chart, matches payer criteria, and assembles the packet, but a clinician or authorization specialist reviews and makes the medical necessity call before anything is submitted.
The system runs inside your environment under HIPAA controls with access restrictions and full audit logging, so PHI stays in your infrastructure and is never sent to outside parties.
It matches the record against the specific payer criteria and flags missing documentation up front, so packets go out complete and evidence-linked rather than getting bounced for gaps.
Bring ai prior authorization to your team
Book a free consultation and we'll map the fastest path to production.