Prior authorization automation that shows every criterion met or not met, with the page that proves it
Every criterion shown met or not met, with the page that proves it.
See one case, screen by screen ↓Software that takes a prior authorization request from intake to decision: it checks eligibility, picks the medical policy, reads the clinical records against each criterion and drafts the notice. In Prior Authorization Automation six agents do the reading and citing; the UM nurse approves and a physician reviewer decides any denial.
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A prior authorization request lands with dozens to hundreds of pages of clinical records — office notes, imaging, labs, procedure notes — faxed, scanned and out of order. The UM nurse reads them against the medical policy, criterion by criterion, while the federal clock runs — from 2026, 72 hours for an expedited request and 7 calendar days for a standard one.
The evidence is usually there. Finding the page is the job, and a missed page can become an “insufficient documentation” denial that is later overturned on appeal. When a record really is missing, the request to the provider often says “please send supporting documentation”, goes out late and brings back the wrong pages — while the clock runs.
Estimated split for a standard request with one criterion missing from the record, by hand and with the solution.
Six agents read, check and cite every page against the medical policy; the nurse approves and a physician decides any denial.
Dr. Paul Ferreira’s office asks Halden Valley Health Plan to authorize a right total knee arthroplasty for Dolores Whitcombe, 67, a Medicare Advantage HMO member. Here is what happens next, screen by screen, in the working solution.
Request PA-2026-1041877 arrives by provider portal: CPT 27447, M17.11, inpatient at Larkfield Regional Medical Center, with 186 pages of records. The intake agent confirms eligibility and that inpatient surgery needs prior authorization, picks medical policy MP-ORTHO-114 v4.2 and starts the standard 7-day clock. The chart reader sorts the pages into 23 documents and marks 2 duplicate pages.
“How this checklist was made” — 5 agents · 2 min 40 s, each step with what it found and how long it took.
Renata does not open a pile of pages. She opens the seven criteria of MP-ORTHO-114, six already ticked with the quoted passage and its page chip, and the clock ring in the header: 4 d 4 h left, due Fri Oct 16, 14:20. The approve button reads “Approve · 1 open” until the last box is ticked.
Renata clicks criterion 1, advanced osteoarthritis on standing X-ray. The chart opens at page 41, the radiology report of Aug 18, with the sentence highlighted. The strip above shows all 186 pages, the evidence pages lit green.
“Severe medial compartment joint space loss, bone-on-bone, with osteophytes. Kellgren-Lawrence grade 4.” — p. 41
At least 6 weeks of supervised physical therapy within the past 12 months: not found in 186 pages, with the searches listed. Page 14 says she “completed a course of PT at Riverbend Physical Therapy, April–May 2026”, and the history agent finds 12 visits approved Apr 3 and billed Apr 6 – May 22. The therapy happened; the notes are what is missing.
The matcher never ticks a criterion without a quoted passage — a claim alone does not close it.
“Request from provider” turns the open row into a fax to Dr. Ferreira’s office: member, request number, the criterion, and three named documents — the Riverbend initial evaluation, visit notes covering at least 6 weeks from Apr 6 – May 22, and the discharge summary — with a reply-by of Wed Oct 14, 14:20 so there is a day left to decide. Renata can edit any line.
The agent drafts; nothing goes to the provider until the nurse sends it.
Renata sends it by fax and portal at 09:52; the clock keeps running. At 10:31 a 14-page fax from Larkfield Orthopaedic Associates is matched to the request by request number and member. The record grows to 200 pages, and criterion 5 ticks on pages 187 and 199, marked “new · received 10:31”.
“12 supervised visits, Apr 6 – May 22, 2026 (7 weeks). Plateaued; pain 7/10 on walking.” — p. 187, 199
The button now reads “Approve · 7 of 7 met”. Renata signs: “I, Renata Alvarez, RN, reviewed each criterion and its record, and approve this request.” Authorization AUTH-77120418 is valid Nov 2, 2026 – Jan 31, 2027, and the approval notice to Dolores Whitcombe and Dr. Ferreira lists every criterion with its page.
Evelyn Tran’s inpatient rehabilitation admission after a stroke is a different case: criterion 2, an intensive program of about 3 hours of therapy a day, is contradicted by the PT note on page 48, while the OT note on page 57 records 90 minutes over two sessions. A nurse cannot deny. Dr. Okonkwo sees both passages, a draft denial notice that names the criterion and the page, and the choice to approve, call Dr. Park peer-to-peer, or sign.
“The criteria matcher does not weigh the two; it shows both.”
Keisha sees decisions on time day by day across all UM nurses — 3 decisions after their clock in six weeks, all standard — and Q3 2026 at 99.1 % of standard requests within 7 days and 98.6 % of expedited within 72 hours. The prior authorization metrics the plan must post each year sit underneath, ready to export.
The same requests, seen by the four people who carry them — what their day looked like, and what it looks like now.
Six agents read, check and cite every page against the medical policy; the nurse approves and a physician decides any denial.
Reads requests from the provider portal, fax and electronic 278 transactions; checks eligibility and benefits; picks the medical policy in force; starts the 72-hour or 7-day clock.
Numbers every page as received, names and dates each document, and marks duplicate pages — so every citation points at a real page.
Checks each criterion of the medical policy against the chart: met, contradicted or not found — always with the quoted passage, document and page, or with what it searched.
For an open criterion, names the exact missing document, finds where the chart mentions it, drafts the fax and portal request with a reply-by time, and matches the reply to the request.
Pulls the member’s past requests, decisions and appeals, and the paid claims that corroborate treatment named in the chart.
Drafts the approval or denial notice in plain language: the service, dates and authorization number for an approval; the criterion not met, the quoted record and page, and reconsideration rights for a denial.
Nurse approves, physician denies. The agents propose; a named person decides.
Nurses and supervisors can ask in plain words — or tell it what to change. Answers point to the page.
Why is criterion 5 open on Dolores Whitcombe’s request?
Criterion 5 of MP-ORTHO-114 needs 6 weeks of supervised physical therapy in the past 12 months, shown by therapy notes. None of the 186 pages is a therapy note. Page 14 says she completed a course of PT at Riverbend Physical Therapy, April–May 2026, and our claims show 12 visits billed Apr 6 – May 22 — so the therapy happened; the record of it is missing. The missing-records agent drafted a fax asking for exactly those notes.
Which requests can I approve now?
Three requests have every criterion met with a quoted passage: Walter Pruitt, MRI of the brain (expedited); Aaliyah Brooks, continuous glucose monitor; Marcus Delaney, MRI of the lumbar spine. I filtered your worklist to them. Each still needs your click and e-signature.
What do knee replacement requests miss most often?
Last quarter, of 412 knee replacement requests, criterion 5 — supervised physical therapy — was left open most often: 31 % arrived without therapy notes. Next: injection tried (12 %) and pain medicine for 3 months (9 %). Most were not missing therapy, only the notes, as on page 14 of Dolores Whitcombe’s record.
Call the provider if a record request has no reply in 48 hours
Done. When a record request has no reply after 48 hours, a call with a short script now goes on the nurse’s list. It applies to 1 request today: Eastgate Pain Center for Harold Benning (PA-2026-1041955), sent Saturday at 15:05. I added it under Settings → Record requests and recorded the change in the audit trail.
13 screens from the working solution, on its sample data. Pick one to see it large.
Who may decide what, the clocks, and how records are asked for are settings — changes are versioned and recorded.
| Setting | Default | Choose from |
|---|---|---|
| Nurse may approve when every criterion is met | On | On · Off — each tick must carry a quoted passage and page |
| Nurse may approve with one open criterion and a note | Off | On · Off — off: an open criterion needs records or a physician |
| Adverse decisions | Physician reviewer | Physician reviewer only, with e-signature |
| Offer a peer-to-peer before a denial | On | On · Off |
| Alert the supervisor before an expedited request is due | 12 hours before | 12 · 24 hours before |
| Alert the nurse before a standard request is due | 24 hours before | 24 · 48 hours before |
| Send record requests by | Fax + portal | Fax + portal · Portal only |
| Reply-by time on the request | 48 hours before due | 48 · 24 hours before due |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample plan data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (KFF, Medicare Advantage prior authorization 2024 — 80.7% of appealed denials overturned; OIG OEI-09-18-00260 — 13% of denials met Medicare coverage rules) · timeframes and denial-reason rules: CMS-0057-F, 42 CFR 422.566(d), 422.568. People, plans, providers and members named on this page are fictional — characters and sample data in the working solution.
Software that takes a prior authorization request from intake to decision: it checks eligibility, picks the medical policy, reads the clinical records against each criterion and drafts the notice. In Prior Authorization Automation six agents do the reading and citing; the UM nurse approves and a physician reviewer decides any denial.
No. The agents never approve or deny, and the criteria matcher never recommends a denial. A nurse may approve only when every criterion is met with a quoted passage; a contradicted criterion goes to a physician reviewer, and a denial is never sent without the physician’s e-signature.
The criteria matcher takes each criterion of the policy in force and finds the passage that meets it or contradicts it, quoted with its document and page. If nothing is found, it says what it searched and where the chart mentions it, and the criterion stays open.
The missing-records agent names the exact document, facility and dates the open criterion needs and drafts a fax and portal request with a reply-by time that leaves a day inside the clock. The nurse edits and sends it; the reply is matched to the request by request number and member, read, and the criterion ticks when the evidence is there.
The intake agent starts the clock when the request arrives — 72 hours for expedited, 7 calendar days for standard — and the clock ring is on every request. Nurses and the supervisor are alerted before a request is due, and the Turnaround screen counts every decision against its clock along with the metrics the plan must post each year.
The medical policy library shows each policy as Medicare coverage or plan criteria. For Medicare Advantage members, Medicare coverage comes first; plan criteria apply only where Medicare’s are not fully established, and are published with their evidence summary and sources.
Yes. Every approval is clicked and e-signed by a nurse, every adverse decision by a physician reviewer, and a peer-to-peer can be offered before a denial. Who may decide what is a setting, and every agent step, decision and setting change is recorded.
The Agentic Solution Engine builds and deploys it from your requirements — your medical policies, notice templates and a sample of past requests — and it goes live once every quality gate has passed. We will walk you through it on your own requests first.
No missed 72-hour or 7-day deadline, and the yearly metrics from the same data.
1-min demoAppeals & Grievances ManagementEvery appeal decided on time, with the full file read and what is new marked.
1-min demoMedical Policy SearchThe criteria that apply, with the policy section and version that say so.
1-min demoWe’ll run Prior Authorization Automation on a sample of your own past requests and medical policies.