Prior auth in hours, not weeks.
Governed execution for the most painful administrative workflow in healthcare. Every step — from intake through care coordination — is traced, compliant, and auditable.
The administrative burden is measurable.
93% of physicians say prior authorization is associated with delays in patient care (AMA physician survey).
The median practice completes 39 prior authorization requests per physician per week, consuming 13 hours of staff time.
Average prior authorization determination takes 14.6 days — with CMS now mandating API-first PA for impacted payers.
Before vs. After: Prior Authorization
Manual Process
- 1Patient intake via paper or portal
- 2Manual eligibility check with payer
- 3Docs scattered across fax, EHR, email
- 4Missing documentation discovered late
- 5Prior auth submitted via portal or fax
- 645-minute hold times for status checks
- 7Denial received after 14+ days
- 8Appeal requires re-assembly of records
Work Graph Execution
- 1Structured intake with auto-verification
- 2Eligibility checked in real-time via API
- 3Doc completeness assessed by AI immediately
- 4Missing docs requested automatically (branching)
- 5Clinical summary generated, PA submitted via FHIR/X12
- 6Payer response tracked with SLA monitoring
- 7Approval decision in 3.2 days average
- 8Care coordination triggered on approval
Real workflow breakdowns.
Each workflow includes HIPAA-aligned policy gates, clinical evidence requirements, and full audit trails.
Intake Triage + Doc Completeness
Verify eligibility, assess documentation completeness, and automatically request missing records — with a cyclic check-and-request loop until the record set is complete.
Prior Auth Submission + Tracking
Generate clinical summary with CPT/ICD-10 codes, submit electronically to payer, and monitor turnaround SLA with automated status checks.
Care Coordination Runbook
On approval, schedule procedure, notify referring physician, coordinate post-op care, and generate patient communication — all with approval gates at clinical decision points.
HIPAA-Aligned by Design
Every Work Graph run enforces HIPAA Security Rule safeguards: administrative (access controls, audit logs), physical (infrastructure isolation), and technical (encryption in transit and at rest, minimum necessary access). Policy gates enforce clinical review requirements. The audit trail captures not just what happened — but the chain of reasoning and evidence that led to each decision.
Measurable outcomes.
Down from 14.6 days. Structured submission + SLA tracking + automated follow-up compresses the timeline.
Up from 62%. Complete documentation and clinical evidence at submission dramatically reduces denials.
13 hours/week reclaimed per provider staff. Reduced denials, fewer appeals, less treatment abandonment.