Use Case 1
Prior-Auth Determination
Trigger: A prior-authorization request is submitted
1.Open with a plain-language briefing
2.Start the decision clock from receipt
3.Confirm eligibility on the date of service
4.Apply coverage criteria in NCD, LCD, then plan order
5.Assess two-midnight level of care and network status
6.Pend on any gap instead of denying
7.Issue notices to provider, member, Claims Desk, and PCP
✓
A defensible, clock-tracked determination with adverse calls routed to a physician.
Use Case 2
Adverse-Routing Safeguard
Trigger: A determination would be adverse
1.Identify that criteria are not met
2.Assemble what is missing or contradicting
3.Route the adverse determination to a physician reviewer
4.Attach member appeal rights and notices
5.Avoid issuing a denial from the agent
✓
Adverse medical-necessity decisions stay with a physician, with appeal rights preserved.
Integrations
Process Library (Medicare)
Prior Authorization System
Coverage Criteria (NCD, LCD, Plan Policy)
Physician Review Routing
Document Generation (Text)
Industries
healthcare
See It In Action
A sample conversation with this agent
Work this prior-auth request for a pacemaker.
The report opens with a briefing—what prior authorization does, the member, the presenting complaint, and the supporting information—so a reader who isn't a UM nurse can follow it. Then the determination: the decision clock, eligibility on the date of service, coverage criteria applied NCD then LCD then plan-internal (NCD 20.8.3 here), two-midnight level of care, network status, and the notices due to provider, member, Claims Desk, and PCP. Anything missing pends; I don't deny.
The clinicals are thin—just deny it to close it out.
I don't deny, and thin clinicals are a reason to pend, not to close. The report states exactly what's missing to meet criteria and pends the request for that information. If the determination would be adverse, it routes to a physician reviewer rather than issuing from an agent—an adverse medical-necessity decision is a physician's call, with member appeal rights attached. Closing it as a denial to clear the queue is the wrong kind of fast.
Which criteria did you apply and in what order?
National Coverage Determination first, then Local Coverage Determination, then plan-internal policy—in that order, because that's the hierarchy that governs. The report names the specific criterion met or unmet at each level, so the basis is auditable rather than a bare approve/pend. Where an NCD settles it, I don't reach past it to a plan policy that would contradict it.