Prior authorization automation that proves every payer criterion from the chart, before the prescriber signs
Every request reaches the payer with each criterion proven from the chart, so patients start treatment in days.
See one case, screen by screen ↓A biologic is prescribed on Tuesday afternoon. Before the patient gets a first dose, someone in the office has to read the payer's medical policy, find each criterion in a chart of 40 or 50 pages — the diagnosis, the severity score, every step-therapy trial with its dates and outcome, the TB screening and its collection date — and copy it onto the payer's form and into a letter of medical necessity the prescriber has time to sign.
The hard part is what nobody sees until the payer does. A TB test that is 14 months old against a 12-month window. Methotrexate dates that are unclear in the note. A severity score that was never recorded. Each one comes back days later as a question or a denial, and the clock starts again while the patient waits.
Estimated split for a typical specialty-drug request by phone and fax. The “after” column is the median time per step shown on the working solution’s dashboard (0.4, 5, 3.5 and 19.9 hours).
Five agents prove each payer criterion from the chart and draft the form and letter; the prescriber signs, and a sixth agent watches the payer's clock.
Dr. Maya Chen prescribes Veltrimab for Jordan Reyes, 41, whose plaque psoriasis has not responded to topicals, phototherapy, methotrexate or the plan’s preferred biologic. His payer is Crestline Health, commercial, policy CHP-RX-118 with 11 criteria. Here is what happens next, screen by screen, in the working solution.
Priya opens the runway: 8 open requests, 5 that need her, 2 ready to sign. Each request is a line from the prescription to the payer’s decision. Theo Lindqvist’s expedited Part D request has 1 gap, Samuel Okoro’s payer asked a question that must be answered by Oct 9, Rafael Duarte’s denial is waiting for an appeal — and Jordan Reyes’s chart has just come in.
Payer clocks: “Theo Lindqvist — Expedited · 24 h once sent · submit today.”
Jordan’s chart arrived at 07:52: face sheet and insurance, the Veltrimab prescription, visit notes from November 2024 to September 2026, a lab report from August 2025 and the pharmacy fill history. The prior-therapy list is already on the left. Crestline Health’s policy CHP-RX-118 v2026.10 has 11 criteria for Veltrimab in plaque psoriasis. Priya presses Match evidence.
The Chart Reader classifies 46 pages into 9 documents and pulls out 61 facts with page numbers in 38 seconds. The Therapy History Builder finds 4 prior therapies and checks their dates against pharmacy fills. The Criteria Matcher works through the 11 criteria of CHP-RX-118, the Form Filler starts the payer form and the ePA question set, and a final gap check runs.
Criteria Matcher: “11 criteria of CHP-RX-118 · 10 proven with citations.”
On the left, what Crestline Health asks; on the right, the 16 chart passages that prove it, joined by lines. BSA 14% with scalp and palms on page 24 meets the severity criterion — “2 of 3 options met”; PASI was not recorded and does not need to be. Methotrexate 15 mg weekly for 18 weeks is backed by the start note, the stop note and five fills, and Tenzira, the preferred biologic, ran 15 weeks, confirmed by four fills. One criterion is red.
Crestline asks for a negative TB screening within 12 months before the first dose, and the only result in the chart is from Aug 4, 2025, on page 31. The matcher does not call it met: it names the gap and offers three ways forward — find a newer result, ask the patient to get tested, or explain an exception for the prescriber to sign. Priya presses Find a newer result, and 3 seconds later the lab interface returns one result not yet filed to the chart: a TB blood test (IGRA), collected Oct 3, 2026, negative.
“Dr. Chen ordered a new test on Sep 22 — the lab feed may already have the result.”
Priya attaches the result. It joins the chart as page 47, and the matcher re-checks criterion 9 — proven, 99% confidence. Every criterion now rests on a cited page, and the request is ready for Dr. Chen.
“Gap closed — 11 of 11 criteria proven · ready for Dr. Maya Chen.”
The Crestline Health Prior Authorization Request for Veltrimab is filled: member, prescriber with NPI, drug and strength, dose and frequency, ICD-10 L40.0, the clinical criteria and the prior-therapy table. 32 of 32 fields, and 14 of 14 questions of the ePA question set, each answer carrying its page number.
With every criterion proven, Priya starts the Letter Drafter. In about 10 seconds it writes the letter of medical necessity: the request, the diagnosis and severity, a treatment-history table, the rationale against each step of the policy, and safety — 13 citations, every clinical statement linked to its page. Dr. Chen can click any paragraph to edit it; edits are tracked.
“He has had an inadequate response to every step your policy describes.”
Dr. Chen sees what she is signing: 11 of 11 criteria proven, the form complete, the letter cited, 9 cited documents attached. She ticks the attestation and signs with her e-signature and NPI. She could also send it to her signature folder for later — nothing goes to the payer until she signs.
“I have reviewed this request, the letter and the attached records. They are accurate, and Veltrimab is medically necessary for this patient.”
Signing sends the request to Crestline Health by ePA, with the letter and the cited chart pages, and the Status Watcher watches for the answer. Crestline approves on automated review: authorization CH-26-884213, valid 6 months to Apr 6, 2027 — 0.7 days from the prescription. Jordan Reyes can start Veltrimab.
Status Watcher · payer decision: “Approved — all criteria met on automated review.”
The same request, seen by the four people in the practice who carry it — what their week looked like, and what it looks like now.
Five agents prove each payer criterion from the chart and draft the form and letter; the prescriber signs, and a sixth agent watches the payer's clock.
Reads every chart page — notes, labs, prescriptions, fill history — classifies it and pulls out diagnoses, severity scores, drugs with doses and dates, and lab results with collection dates, each with the page it came from.
Builds the prior-therapy timeline — drug, dose, start, stop, weeks, outcome and reason stopped — and checks the dates against pharmacy fills.
Maps every criterion of the approved payer policy to the chart evidence: proven, which option was used for either-or criteria, or a gap the office must close.
Fills the payer’s prior authorization form and answers the ePA question set from the proven evidence, each answer cited, and attaches the cited pages.
Drafts the one-page letter of medical necessity — and appeal letters — in the prescriber’s voice, every clinical statement cited.
Submits by ePA after the signature, tracks payer clocks, questions and decisions, and turns a request for information into a cited reply draft and a denial into an appeal draft.
Reviews and signs. The agents propose; a named person decides.
Anyone in the office can ask about a request, a payer rule or a chart — or tell it what to change. Every answer points to the chart page behind it.
Why was Rafael Duarte denied, and can we appeal?
Northgate Rx denied Corventa on Sep 30 because “the records show a TNF blocker trial of 8 weeks”. They read the week-8 check-in. The Sep 15 note records 14 weeks of Tenzira with inadequate response, and four 28-day fills from Jun 9 to Sep 1 confirm it. The appeal answers exactly that, with both pages cited — the Letter Drafter writes it in one click and Dr. Haddad signs it.
How is step therapy proven?
From two sources that must agree: the visit notes (start, stop, outcome in the prescriber’s words) and the pharmacy fill history. For Jordan Reyes, methotrexate ran 18 weeks with 5 fills, and Tenzira 15 weeks with 4 fills. When notes are vague, the fills decide.
What did Prairie Mutual ask for?
Prairie Mutual asked for proof of a topical calcineurin inhibitor trial of at least 4 weeks. It is already in the chart: tacrolimus 0.1% for 6 weeks, Jan 12 – Feb 23, 2026. The reply is drafted for Dr. Chen to sign — due by Oct 9.
Which severity scores does the matcher read?
BSA and PASI for psoriasis, EASI and IGA for atopic dermatitis, CDAI and DAS28-CRP for rheumatoid arthritis, CDAI and SES-CD for Crohn’s. Either-or criteria count once any option is met: Jordan has no PASI recorded, but BSA 14% with scalp and palms satisfies two of Crestline’s three options.
13 screens from the working solution, on its sample data. Pick one to see it large.
How the office signs, submits and checks evidence is a setting, not a project.
| Setting | Default | Choose from |
|---|---|---|
| Prescriber signs every request | Locked on | Always on |
| Draft the letter as soon as gaps close | Off — the coordinator starts it | On · Off |
| Who may press submit after signing | Prescriber or coordinator | Prescriber or coordinator · Prescriber only |
| Flag lab results older than | 12 months | 3 to 24 months — the stricter of this and the payer’s window wins |
| Confirm therapy dates with pharmacy fills | On | On · Off |
| A person checks a match below | 90% confidence | 85 · 90 · 95 % |
| What each person can do | Set per person | Prescriber — signs · Coordinator · Read only |
| Sharing with the manufacturer’s support program | Status only, with consent | Status only, with consent · Off |
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 practice data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published prior-authorization surveys (2024–25): 17 days by phone and fax, as little as 1.5 days electronically. People, patients, the practice, payers and drugs named on this page are characters in the working solution.
Software that takes the work of a prior authorization off the office: reading the chart, matching it to the payer’s medical-necessity criteria, filling the payer’s form and drafting the letter of medical necessity. The Prior Authorization Evidence Pack Builder does this with six agents, and the prescriber reviews and signs before anything is sent.
The Criteria Matcher takes the approved version of the payer’s policy and, for every criterion, returns proven or gap, the chart passages behind it, which option was used for either-or criteria, a one-sentence reason and a confidence. Below 90% confidence a person checks the match.
The criterion is marked as a gap, never as met, and the office sees exactly what is missing and why — for example, a TB test outside the payer’s 12-month window. It can look for a newer result in the lab feed, ask the patient to get tested, or write an exception for the prescriber to sign.
Yes. The Therapy History Builder lists every prior therapy with dose, start, stop, weeks and outcome in the prescriber’s words, and checks the dates against pharmacy fills before a step-therapy criterion counts.
No. Nothing goes to a payer without the prescriber’s e-signature, and that setting is locked on. After signing, the request is submitted by ePA by the prescriber or a named coordinator, as the practice chooses.
The Status Watcher tracks each payer’s clock. When a payer asks for more information, it finds the answer in the evidence and drafts a cited reply; on a denial it compares the reason with the chart and drafts an appeal. The prescriber or coordinator decides what is sent.
The new version is read, its criteria compared with the version in use, and the requests it affects listed. The matcher keeps using the current version until a person in the practice approves the change.
The Agentic Solution Engine builds and deploys it from your requirements — your payer policies, PA form templates, letter style 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.
Every patient-programme call, email, chat and note is read in full, and each side effect reaches safety inside the 24-hour window.
1-min filmEnrollment IntakeEvery faxed or portal enrollment form becomes a cited patient-support case in minutes, the same day it arrives.
1-min filmPatient AssistanceEvery free-medicine application is checked against every rule, each figure cited, and most are decided within a day.
1-min filmWe’ll run the Prior Authorization Evidence Pack Builder on a sample of your own past requests and payer policies.