Agentic Prior Authorization

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Agentic Prior Authorization

Sector: Healthcare

Agentic Prior Authorization & Utilization Management

The Challenge: Prior Authorization (PA) is the “administrative tax” of healthcare, costing the US system over $30 billion annually. The process is plagued by “Information Asymmetry”: providers don’t know the exact payer rules, and payers don’t have the granular clinical context. In 2026, the volume of specialty drug requests has outpaced human review capacity by 400%.

The Technical Solution

We deploy a Federated Multi-Agent System (MAS) built on a LangGraph orchestration layer.

The Intake Agent

Uses a Multimodal LLM (Gemini 1.5 Pro or similar) to ingest faxed images, handwritten notes, and structured HL7 FHIR feeds. It performs entity extraction to identify the patient, provider, and requested procedure.

The Clinical Context Agent

Queries the EHR via specialized RAG (Retrieval-Augmented Generation). It doesn’t just pull the latest note; it uses a “Temporal Query” to track the progression of the disease (e.g., “Find all failed conservative therapies for this patient’s back pain over the last 6 months”).

The Policy Reasoning Agent

This is the core “Brain.” It operates on a specialized vector store containing thousands of Medical Policy Bulletins. It uses Chain-of-Thought (CoT) reasoning to compare the Clinical Context against the Policy Criteria.

Agentic Logic & Autonomy

The breakthrough in 2026 is the Execution Agent. If the Policy Agent finds that a “required MRI report” is missing, the Execution Agent doesn’t just flag it. It checks the provider’s radiology portal, locates the report, and fetches it. If it’s truly missing, it drafts a context-aware secure message to the clinic: “Dr. Smith, PA #1234 for Patient Doe is pending only the L4-L5 MRI report from Feb. Click here to upload.”

Governance & GRC

To satisfy CMS 0057-F compliance, the system generates a “Clinical Evidence Trace.” This is an immutable log showing exactly which page of which medical record justified the approval. If a denial is recommended, the system must provide a “Human-in-the-Loop” (HITL) trigger, where a Medical Director reviews the AI’s logic before the final decision is sent.

Speed

Turnaround time drops from 10 days to 90 seconds for 75% of cases.

Accuracy

Reduces “Appeal Rates” by 40% because the initial submission is complete.

ROI

A mid-sized payer saves $12M annually in manual labor and clinical review costs.

Agentic Prior Authorization

Sector: Healthcare

Agentic Prior Authorization & Utilization Management

The Technical Solution

The Intake Agent

The Clinical Context Agent

The Policy Reasoning Agent

Agentic Logic & Autonomy

Governance & GRC

Speed

Accuracy

ROI

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Core capabilities.

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Agentic Prior Authorization

Sector: Healthcare

Agentic Prior Authorization & Utilization Management

The Technical Solution

The Intake Agent

The Clinical Context Agent

The Policy Reasoning Agent

Agentic Logic & Autonomy

Governance & GRC

Speed

Accuracy

ROI

Our Head Office

Company

Investor