Healthcare: Prior Authorization Automation
Prior authorization automation: weeks to seconds.
Model payer criteria as a graph, traverse the patient record for automated first pass adjudication, and file through Surescripts ePA: with explainable, evidence cited decisions both provider and payer can trust.
The short answer
How does AI prior authorization work?
Prior authorization is a payer's requirement that a service or medication be pre approved against coverage criteria. Those criteria are essentially policy decision trees. AI prior authorization models each payer's criteria as a graph, then traverses the patient's record to check (automatically) whether the criteria are met, producing a first pass approve/deny with the exact rule and evidence attached. Straightforward requests are adjudicated in seconds and filed electronically through Surescripts ePA, while edge cases route to a human with the analysis already done.
What we build
Prior Authorization Automation, engineered on your data.
Payer criteria as a graph
Encode each payer's prior auth policy as a traversable decision graph instead of a static PDF or a human's memory.
Automated first pass adjudication
Traverse the patient record to auto check whether criteria are met, approving straightforward requests without manual review.
Explainable decisions
Every denial cites the exact rule and the patient evidence that failed it: appealable, auditable, and defensible.
Surescripts ePA filing
File medication prior authorizations electronically through the Surescripts ePA network, at the point of prescribing.
Utilization management workflow
Slot into existing UM queues so reviewers see the analysis first and spend their time only on genuine edge cases.
Reduced administrative burden
Cut the manual review load on both provider and payer and shorten the time patients wait for care.
FAQ
Prior Authorization Automation: frequently asked questions.
What is electronic prior authorization (ePA)?
ePA replaces fax and phone prior authorization with a structured electronic transaction: for medications, it runs through the Surescripts ePA network at the point of prescribing. The prescriber answers the payer's criteria questions in the EHR and gets a determination in the workflow instead of days later.
Does AI prior authorization replace utilization management staff?
No: it front loads their work. The AI handles the high volume, clearly approvable requests and hands reviewers the genuinely ambiguous ones with the criteria already checked and the evidence assembled. Staff spend their expertise on judgment calls, not data gathering.
How are denials kept defensible and appealable?
Because criteria are modeled explicitly, every automated decision points to the specific rule and the specific patient fact behind it. That makes denials transparent to the provider, straightforward to appeal, and auditable for the payer: the opposite of an opaque model output.
Can this integrate with our existing payer and EHR systems?
Yes. Prior auth automation reads the patient record through FHIR/HL7 (see EHR integration), grounds decisions in the same knowledge graph as your clinical AI, and files medication ePA through Surescripts: so it fits the systems you already run rather than replacing them.
Explore the healthcare stack
Related healthcare capabilities.
Pharmacy & e Prescribing
Surescripts authorized e prescribing, prior authorization, and medication history on the NCPDP SCRIPT standard: grounded in RxNorm/NDC drug data and enriched with openFDA, DailyMed, and FAERS.
Learn moreClinical GraphRAG & Decision Support
Ground every LLM answer in your clinical knowledge graph and the patient's record, with fact level citations your compliance team can click. Guaranteed hallucination reduction, in writing.
Learn morePatient 360 & Record Linkage
Resolve the same patient across EHR, claims, lab, pharmacy, and device data into a canonical patient graph: the foundation for care coordination, risk stratification, and every downstream clinical AI.
Learn moreReady to build prior authorization automation on grounded, compliant AI?
A 6 week pilot with one use case, fixed scope, and outcomes guaranteed in writing: hit the target or the pilot is free.