Workflow — Prior Authorization

Prior auth in 3 minutes, not 30.

Physician order, clinical notes, lab results, imaging, prior treatment history → match clinical evidence to payer medical-necessity criteria (InterQual, MCG), build PA narrative, identify required attachments. Submitted via payer portal, fax, or EDI 278; tracked to approval / denial in Epic, Cerner, athenahealth, Cohere, or Surescripts. Replaces prior-auth specialists at provider, payer, or PBM at a fraction of the per-PA cost.

Take the AI Assessment Get a Per-PA ROI Model

12–18 min

Per PA at the nurse / admin desk

$35B

Annual nationwide PA labor problem

60–85%

Routine PA volume off the specialist desk after AI cutover

What This Replaces

The PA Specialist Reading Every Clinical Record by Hand

The work the prior-auth specialist does on every PA — and the cost of leaving it there.

The labor

Prior authorization today moves through PA specialists at provider, payer, and PBM operations centers — onshore at $25–$45 per hour for nurses and clinical specialists, plus heavy offshore for high-volume specialties (radiology, oncology, cardiology) at Cognizant, Optum, Conifer Health, R1 RCM, GeBBS Healthcare Solutions, Access Healthcare, Sutherland, EXL Healthcare, and AGS Health. Per-PA time runs 12–18 minutes of nurse / admin time. Prior auth is a $35B annual labor problem nationwide; CMS interoperability rules and the 2024 PA reform rules are pushing payers and providers toward faster cycles.

The cycle time

Standard PA cycle runs hours-to-days from physician order to authorization decision, with longer cycles when payer-portal access requires multiple sign-ins, when clinical-evidence packaging needs senior-clinician review, or when peer-to-peer review is required. CMS PA-timeliness rules (urgent 72 hours, standard 7 days under 2024 reforms) add deadline pressure. Every hour a PA sits unprocessed is an hour the patient waits for a procedure, the provider holds an open chart, and the payer carries care-coordination cost.

The Workflow

Input · Analysis · Output

What goes into PA processing, what we do to it, and what shows up in the EHR / care-management system.

Input

Physician order + clinical evidence

Physician order with CPT / HCPCS code
Clinical notes from EHR (problem list, progress notes)
Lab results and imaging studies
Prior treatment history
Payer-specific PA form requirements
InterQual / MCG criteria for the procedure
Patient eligibility and benefit verification

Analysis

Match, package, validate

Medical-necessity match against InterQual / MCG criteria
Per-payer-policy review (medical policy, formulary)
PA narrative drafted with clinical-evidence chronology
Required-attachment identification per payer
Step-therapy / fail-first eligibility check
Place-of-service and CPT / HCPCS validation
Confidence score per finding; exceptions to PA specialist queue

Output

PA submission into the SoR

Epic (App Orchard / FHIR APIs)
Cerner / Oracle Health (FHIR APIs)
athenahealth (REST APIs)
Cohere (published integration)
Surescripts (prescriber-portal integration)
Payer portal, fax, or EDI 278 submission
Per-PA audit trail with criteria-match basis

Side by Side

Prior Authorization Today vs. With Last Rev

The numbers that matter: cycle time, per-PA cost, accuracy, and patient-care impact.

Dimension	PA Specialist Processing	Last Rev Prior Authorization
Cycle time, order received to PA submitted	12–18 minutes per PA	3–5 minutes per PA
Per-PA unit cost	$25–$45/hr nurse / specialist translated per-PA	Per-PA, benchmarked at 25–45% of specialist unit cost
CMS PA-timeliness compliance	At-risk on volume spikes	Cycle time dramatically inside CMS urgent / standard windows
Medical-necessity match consistency	Variable — specialist judgment, drift across teams	InterQual / MCG criteria applied identically per PA
PA-narrative quality	Templated narratives with manual data fill-in	Per-PA narrative with clinical-evidence chronology and criteria-citation
EHR / care-management integration	Manual data entry into Epic / Cerner / Cohere	Direct via documented Epic / Cerner / athena / Cohere / Surescripts integrations
Audit log per finding	Specialist notes, no criteria-level lineage	Source clinical evidence + criteria citation + model version + confidence per element

How It Works

From Physician Order to Authorization Decision

Five steps. Every one logged. Every one reversible if your confidence threshold isn't met.

Submission Lands

Physician order with CPT / HCPCS code from the EHR — paired with clinical notes, lab results, imaging studies, prior treatment history, payer-specific PA form requirements, InterQual / MCG criteria for the procedure, and patient eligibility / benefit verification.

Extraction & Classification

Medical-necessity match against InterQual / MCG criteria. Per-payer-policy review (medical policy, formulary). PA narrative drafted with clinical-evidence chronology. Required-attachment identification per payer. Step-therapy / fail-first eligibility check. Place-of-service and CPT / HCPCS validation.

Validation Against PA Bar

Findings validated against the payer's medical policy and the provider's PA playbook. Anything below your confidence threshold per finding is routed to the PA specialist review queue — final clinical-evidence sign-off remains with the regulated entity.

Push to System of Record

PA submitted via payer portal, fax, or EDI 278. Tracked to approval / denial in Epic, Cerner / Oracle Health, athenahealth, Cohere, or Surescripts via the documented integration. PA status updates feed the EHR for clinician visibility.

Audit Log Persisted

Every criteria match, narrative element, and submission event logged with the source clinical evidence, model version, prompt, and confidence score. Payer-denial-defense-ready and yours.

Compliance & Defensibility

Built to Meet the Quality Bar Utilization Management Already Runs On

CMS Interoperability and Prior Authorization Rule

CMS-0057-F (CMS Interoperability and Prior Authorization Final Rule) timeliness requirements (urgent 72 hours, standard 7 days) tracked. Per-payer PA-API support respected as the API ecosystem rolls out across MA, ACA, Medicaid managed-care, and CHIP plans.

InterQual / MCG criteria fidelity

InterQual (Change Healthcare) and MCG Health (Hearst Health) medical-necessity criteria applied per the procedure. Per-criteria-set version tracked so audit reviews resolve cleanly. Per-payer customization of criteria respected per onboarding.

No clinical-determination authority

We don't make the clinical or medical-necessity determination. We tag the order with the criteria-match evidence and the source clinical chronology so the medical director, clinical reviewer, or peer-to-peer-review physician makes the call on a richer file. Final approval / denial remains with the regulated entity.

PHI / 42 CFR Part 2 / HIPAA / HITRUST posture

Clinical records contain PHI under HIPAA, plus substance-use information under 42 CFR Part 2 in some cases. Deployable in your VPC or our SOC 2 / HITRUST / HIPAA-aware environment. Encryption in transit and at rest; retention policies tied to your HIPAA / state-specific recordkeeping rules.

Common Questions

What Providers, Payers & PBMs Ask About Prior Authorization

Those are the PA platforms that run the workflow itself. The competitor on this page is the PA specialist labor that does the actual clinical-evidence packaging and submission work — typically nurses and clinical specialists at $25–$45 per hour fully loaded plus offshore PA support at Cognizant, Optum, Conifer Health, R1 RCM, GeBBS Healthcare Solutions, Access Healthcare, Sutherland, EXL Healthcare, and AGS Health. We undercut that labor cost, integrate directly into your existing PA platform / EHR / care-management deployment, and deliver structured PA submissions into the system of record.

Most providers, payers, and PBMs keep the PA arrangement in place during pilot and early production — we route exceptions, complex multi-condition cases, and any PA that genuinely requires senior-clinician judgment to the team you already have. Volume to the offshore PA desk drops 60–85% on routine PA processing once cutover completes. You renegotiate at the next renewal from a much better position, often shifting the relationship to higher-complexity work like peer-to-peer-review prep or appeal-letter drafting.

Our pilot success threshold is medical-necessity-match and clinical-evidence-package accuracy at parity with or above your incumbent PA specialist process, measured on the same shadow-data sample of historical PAs. Anything below your defined confidence threshold per finding is routed to the specialist review queue — your call which queue, ours or yours.

InterQual (Change Healthcare) and MCG Health criteria sets are applied per the procedure and the payer. Per-payer customization of criteria (medical-policy bulletins, formulary-specific carve-outs, plan-specific benefit rules) is configured during onboarding. The audit log records which criteria-set version applied to each PA at the time of review.

CMS-0057-F PA-API support and timeliness requirements (urgent 72 hours, standard 7 days) are tracked per PA. As payers roll out PA APIs across MA, ACA, Medicaid managed-care, and CHIP plans, the workflow integrates against the API where available and falls back to portal / fax / EDI 278 where the API isn't available yet.

Yes — through the documented integration surface each platform supports. Epic via App Orchard / FHIR APIs; Cerner / Oracle Health via FHIR APIs and Cerner Open Developer Experience; athenahealth via REST APIs; Cohere via published integration patterns; Surescripts via the prescriber-portal integration. Your IT, clinical, and compliance teams review and approve service accounts. We do not require platform-side custom development.

PA pilots typically run 6–8 weeks: 1–2 weeks of integration and per-payer / per-specialty PA-rule mapping with the utilization-management team, 4 weeks of shadow-mode running on real PAs with no payer-side submissions, 1–2 weeks of supervised cutover on a constrained scope (one specialty, one payer, one site). Production rollout is staged after the pilot meets your accuracy and clinical-management sign-off.

We benchmark against your current per-PA fully-loaded cost — typically derived from $25–$45 per hour nurse / specialist rates translated into per-PA economics. Our target is 25–45% of that per-PA cost at higher accuracy and faster cycle time. Pricing structures around volume tiers and outcome SLAs (CMS-0057-F timeliness compliance), not hourly billable rates.

Two Ways to Start

Take the AI assessment for a structured read on prior-authorization feasibility. Or talk to us if you already know PA backlogs are the constraint on patient care or member satisfaction.

Self-serve · 8 minutes

Take the AI Assessment

A short structured assessment that maps your monthly PA volume, EHR / care-management platform, and PA-specialist staffing model to AI feasibility and ROI.

Talk to a specialist

Get a Per-PA ROI Model

Send us your monthly PA volume, your EHR / care-management platform, and your PA-specialist staffing model. We'll come back with a per-PA unit-cost comparison and a 6–8 week pilot plan in 5 business days.

Other Workflows

More Healthcare Admin Workflows We Replace

The same approach, applied to the other document-heavy labor lines on your healthcare-admin budget.

Clinical Denial Appeal

Denial letters and medical records → payer-policy-cited appeal letters with evidence chronology.

Pharmacy Prior Authorization

Prescription, patient history, formulary, step-therapy → PBM PA submission with the fewest steps.

HCC Coding Review

Progress notes, discharge summaries → HCC capture per MEAT criteria. Submission to CMS RAPS/EDS.

Inpatient / Outpatient Coding

H&P, op reports, discharge summaries → CPT, ICD-10, MS-DRG. AAPC / AHIMA-aligned coding.