Prior Authorization

Prior authorization is the flagship closed loop. New cases surface automatically with the clinical evidence assembled and the payer's coverage rules already matched, so the reviewer starts from a drafted packet instead of a blank form.

1. Detect — a service needing authorization is identified from the encounter.
2. Evidence — relevant clinical documentation is gathered from the record.
3. Rules — the payer's policy for the procedure/plan is matched.
4. Predict — a historical approval likelihood is estimated for this payer + code.
5. Draft — a submission packet with the medical-necessity narrative is composed.
6. Gate — a reviewer approves, edits, or rejects the packet.
7. Submit → Decide — the packet is submitted and the payer's decision is tracked on the case timeline.
8. Appeal → Learn — denials flow straight to Appeals; every outcome sharpens the next prediction.

The drafted packet always stops for a reviewer before submission. Nothing is auto-submitted to a payer.

Reviewers and clinicians approve packets; admins configure payer rules.

Submission, payer decision, and appeal outcome are recorded per case and feed the approval-likelihood model for that payer and procedure.

• Work from the Worklist — cases are pre-sorted with evidence attached.
• Edit the narrative inline at the gate; your edits are captured, not overwritten.
• Denied cases don't need re-keying — open the case and continue in Appeals.