Prior auth workflows that move faster—with audit-ready automation.
Extract, summarize, and route clinical documentation with PHI controls and exception approvals.
The problem
- Prior auth requests take 5–15 days on average, delaying patient care
- Staff spend 40%+ of time on manual form completion and follow-ups
- Denials due to incomplete documentation or coding errors
- No visibility into bottlenecks or approval probability
- Regulatory requirements demand complete audit trails
How it works
Ingest Documents
Receive clinical documents from EHR, fax, or portal—normalize formats and tag metadata.
Classify & Extract
Identify document type, extract structured fields, and flag missing data.
Summarize Justification
Generate a payer-ready clinical justification summary grounded in source documents with citations.
Completeness Checks
Validate required fields, cross-reference payer criteria, and flag gaps before submission.
Route to Reviewer
Send complex or low-confidence cases to clinical reviewers with pre-populated summaries.
Generate Response Packet
Assemble submission-ready packet with justification, supporting docs, and cover letter.
Log Decisions
Record every extraction, summary, routing decision, and reviewer action in an immutable audit trail.
Deliverables bundle
Integrations
Controls included
- HIPAA-compliant data handling
- PHI encryption at rest and in transit
- Role-based access to patient data
- Clinical review gates for complex cases
- Audit trail designed for regulatory compliance
Pilot plan
Map existing prior auth workflows, payer requirements, and EHR integration points.
Document pipeline, extraction models, rules engine, and reviewer UI.
Parallel run with manual process, accuracy measurement, and clinical review.
Controlled production deployment, staff training, and monitoring activation.
Expected outcomes
All figures are estimates based on comparable engagements
- 20–40% reduction in manual handling time per authorization (estimate)
- Fewer rework loops due to completeness checks (estimate)
- 15–25% improvement in first-pass approval rate (estimate)
- Comprehensive audit trail for processed authorizations
Risks & mitigations
Risk: PHI leakage through extraction or summarization
Mitigation: PHI masking in logs; encrypted processing pipeline; access-controlled reviewer UI.
Risk: Incorrect or misleading clinical summaries
Mitigation: All summaries include inline citations; human review required for complex cases; eval harness tracks accuracy.
Risk: EHR integration complexity
Mitigation: Standard FHIR/HL7 interfaces with fallback to manual data entry for unsupported systems.
Frequently asked questions
Want to talk through your use case?
Book a 30-minute discovery call. We'll scope the workflow, map integrations, and outline security controls—no commitment required.