Prior authorization automation that your staff stay in charge of.
An agent reads the order and the chart, checks the payer's rules, assembles the evidence and drafts the request. Your team reviews and submits. Denials come back grouped by reason with a draft appeal.
- Pilot
- 6–8 weeks
- Ideal for
- Physician groups, specialty practices, RCM companies
- Works with
- FHIR, X12 278, payer portals, your practice management system
- Control
- Staff approve every submission
The challenge
Where prior-auth time goes
Staff spend hours finding the right documents, checking payer criteria, re-keying data into portals and chasing status. Denials often repeat for the same reasons because nobody has time to analyse them.
Spending on prior-authorization AI grew roughly tenfold in 2025, the fastest of any healthcare AI category. The practices that benefit most keep people in control and automate the searching and paperwork.
Sources: Capstone Partners report via HIT Consultant, Sep 2026
Scope
What the agent does
- Requirement checkDetermines whether a service needs authorization for the patient's plan and what documentation the payer expects.
- Evidence packetFinds the relevant notes, results and history and assembles them with a short clinical summary.
- Status trackingChecks status through APIs or portals and alerts staff when action is needed.
- Denial analysisGroups denials by reason code and payer so you can fix the causes, not just the cases.
- Appeal draftsDrafts appeal letters with cited evidence for your team to edit and send.
How it runs
Clear stages. You decide at the end of each.
Baseline
Measure current turnaround, denial rate and staff time on a sample of cases.
1–2 weeksPilot
One specialty or payer group, agent drafts beside staff.
6–8 weeksMeasure
Compare turnaround, first-pass approvals and hours saved.
2 weeksExpand
Add payers and specialties.
ongoingQuestions
What teams ask us about this.
Does the AI submit requests on its own?
Not unless you decide it should. By default staff review and submit every request.
How does this relate to CMS-0057-F?
As payers launch Prior Authorization APIs, the agent can submit and track requests through them instead of portals. We build for both.
What results should we expect?
We agree the measures up front, such as turnaround time, first-pass approval rate and staff hours, and report them from your own data at the end of the pilot.
Related
Start a project
Tell us what you want AI to do. We'll tell you if it can.
A 30-minute call with an engineer. You leave with a straight answer on feasibility, rough cost and the first step.