Requirement checking
Payer, plan, procedure and diagnosis combinations checked before the service is scheduled, so the patient is not surprised at the desk.
10 · Revenue cycle
AI Prior Authorization Agent
Prior authorization is the highest-friction, lowest-value work in a practice. The agent does the checking, the packet assembly and the chasing — and flags the ones that are about to be denied.
Agent at a glance
- StatusIn development
- CategoryRevenue cycle
- Deployment2–4 weeks, shadow mode first
- Review modelHuman approval per action, configurable
- Headline metric< 48 hrs Packet to submit
- EvidenceFull action log, exportable any time
16 hrs
Staff time saved weekly
Typical for a practice handling 60–100 auths a week.
< 48 hrs
Packet to submission
Clinical documentation assembled from the chart, not faxed around.
< 1%
Missed deadlines
Every request carries its payer deadline and escalation path.
What it does
Everything in this agent, in writing.
Clinical packet assembly
Chart notes, imaging, labs, prior treatments and conservative-care history gathered into the payer's required format.
Submission across channels
Payer portals, fax and clearinghouse transactions, with the confirmation number and timestamp recorded.
Status tracking
Automated status checks on a fixed cadence until a decision is issued, with escalation when a payer stalls past its own published window.
Peer-to-peer scheduling
When a denial requires a physician conversation, the agent proposes times and books it, then briefs your clinician.
Denial and appeal handoff
Auth denials routed to the Denials Agent with the packet and the payer's stated reason already attached.
Deployment
Live in weeks, not quarters.
01
Auth inventory
We quantify your volume by payer and service line and find the recurring bottlenecks.
02
Payer matrix build
Requirements, forms, portals and timelines documented per payer.
03
Shadow mode
The agent prepares packets; staff submit, so accuracy is measured before autonomy.
04
Full operation
Submission and tracking handled, with exceptions and peer-to-peers routed to clinical staff.
Guardrails
What it will never do.
These limits hold regardless of configuration. They exist so that you can put an agent in front of patients without putting your licence next to it.
- Never fabricates or embellishes clinical information to support an authorization
- Clinical content is drawn only from the signed record, with the source note cited
- Peer-to-peer conversations are always conducted by a qualified clinician
- Payer deadline calendar enforced with escalation before a window closes
- Outcomes and denial reasons reported by payer so patterns become negotiating leverage
Human in the loop, by your choice
Every action can require approval before it commits. Start with all of prior auth agent queued to your staff or to ours, watch the accuracy numbers, then widen autonomy workflow by workflow — or leave it queued forever. Both are supported.
Escalations land with certified people
Our review queue is staffed by the same certified coders, billers and credentialing specialists who run our managed services. Not a support desk, and not a chatbot watching a chatbot.
Full evidence trail
Input, decision, action, confidence, model version, reviewer and timestamp — retained and exportable as CSV or JSON, including after you leave us.
What we report against
Operational targets for this agent. They are internal commitments measured on your own data, reported monthly — including the misses.
< 48 hrs
Packet to submit
< 1%
Missed deadlines
70%+
First-pass approval
16 hrs
Weekly time saved
Works with your systems
Your EMR, your numbers, your data.
- Availity
- Change Healthcare
- Waystar
- Payer portals
- Athena
- eClinicalWorks
- NextGen
- Epic
We integrate through FHIR and HL7 where the vendor supports it, and through secure automation or structured document intake where it does not. No API required, no vendor commission taken.
FAQ
Common questions.
Can it access payer portals directly?
Yes, through secure automation where the payer permits it and through clearinghouse transactions where they exist. Credentials are stored in a vault with per-user access logging, never in plain text.
What if a payer requires a phone call?
The agent prepares the case, gets through the queue and handles the administrative portion, then hands to a human for anything clinical. Hold time stops being your staff's problem.
Does it help with peer-to-peer reviews?
It identifies the need, proposes times that work for your clinician and the payer's reviewer, books it, and prepares a one-page brief with the clinical justification.
Will it work for high-cost drugs and infusions?
Yes. Drug authorizations are among the highest-friction, and they benefit most — site-of-care requirements, step therapy and buy-and-bill rules are all handled.
Related agents
Usually deployed together.
11
In development
AI Denials & Appeals Agent
Works deny-rail and clearinghouse rejections continuously: categorises each denial, drafts the appeal with clinical support attached, and escalates the patterns that keep recurring.
- Every denial categorised, owned and worked to resolution
- Appeals drafted with the clinical documentation attached
- Root-cause patterns fed back to coding and the front desk
12
In development
AI Payment Posting Agent
Reads ERAs and EOBs, matches payments to claims, posts insurance and patient amounts, verifies contractual adjustments, and reconciles every posting against the bank deposit.
- ERA and EOB posting with line-level matching
- Contractual adjustments verified, underpayments flagged
- Daily reconciliation to bank deposits with exceptions queued
13
In development
AI Credentialing Agent
Keeps every provider's credentials, CAQH profile, payer enrolment and expirables current — prefilling applications, chasing payers and escalating before anything lapses.
- Applications prefilled from a single source-of-truth profile
- Payer follow-up on a fixed cadence with escalation paths
- Expirables tracked with 120/90/60/30-day escalation
See it run on your own workflow.
A 30-minute demo using your scenarios, your payer mix and your systems. We will show you the guardrails and the audit log, not just the happy path.
A 30-minute call with an operations lead. No obligation, no sales sequence, and we will say so if you do not need us.