Prior Authorization Automation

Prior auths and denials eat the billing team, and the answer on the table is usually more people.

One health plan, measured, and published in full.

One workflow, one situation, and the person who signs is not the person who feels it.

Your decision history is the training data. Not a vendor's model of your industry.

Find out what is actually in your queue first.

Learn your own rules

Sort before you staff

Keep a person on the judgement

Hand it over with an owner

Triage prior authorization requests by urgency, complexity and completeness so reviewers spend judgement on the cases that need it. Platform neutral, built on your own decision history.

Sort the prior auth queue so people spend judgement where it is needed. Built on your own decision history, platform neutral.

Urgent requests carry a turnaround commitment and the team meets it some of the time. At the health plan in the case study below, 61 times in 100.

That plan priced the extra reviewers needed to close the gap at $2.8M a year before looking at the queue itself.

A queue gets worked in the order it arrives, so the same clinical attention goes to a case that needed none and a case that needed all of it.

Average review fell from 4.2 days to 6 hours on AI-handled cases

18,000 additional cases absorbed a month without adding staff

VP Revenue Cycle, Practice Administrators and Billing Directors, who own the queue and start the search

Revenue cycle leaders who need the audit trail to survive a review, not just a faster number

A CFO or executive sponsor, who releases the budget and asks whether the improvement is worth the investment

We read your past decisions rather than writing a policy from scratch. The clinical rules the queue already runs on are in that history, and they are yours rather than a generic model of your sector.

Triage ranks incoming requests by urgency, complexity and completeness. The simple cases route to automated approval, the rest route to a reviewer, and urgent requests go to the front of the queue whenever they arrive.

Reviewers hold the cases that carry clinical judgement. When a reviewer overrides a recommendation the correction feeds back into the model rather than into a log, which is how accuracy moved at the plan in the case study.

You get the monitoring, the override rate, the audit trail a reviewer can defend, and a named owner on your side. A workflow nobody owns goes stale the same way a catalog does.

Most of a prior auth queue does not need a reviewer. It needs sorting.

For VP Revenue Cycle, Practice Administrators and Billing Directors who are pricing up headcount to meet a turnaround obligation, when the expensive judgement is being spent evenly across cases that need wildly different amounts of it.

Prior auths and denials eat the billing team, and the answer on the table is usually more people.

A BlueCross BlueShield affiliate handled 42,000 prior authorization requests a month at an average of 4.2 days each. Triage learned the plan's own clinical rules from 18 months of its past decisions, then sorted incoming requests by urgency, complexity and completeness.

These are that engagement's numbers, not a price list. What your queue does depends on what is in it, which is what the scoping work is for.

One workflow, one situation, and the person who signs is not the person who feels it.

Your decision history is the training data. Not a vendor's model of your industry.

The runtime and the model are chosen with you during scoping, against your own cloud, data residency and procurement position. We do not arrive with a platform to sell, so the choice can go the way the evidence points.

Book a consult and we will look at your volumes, your turnaround obligation and how much of the queue needs judgement at all. If sorting does not move your numbers we will say so before any commitment.