Use Case 1
Routine BH PA Submission
Trigger: Provider requests PA for behavioral health service
1.Determine PA requirement against plan and BH carve-out rules
2.Assemble clinical documentation packet from EHR
3.Generate medical necessity narrative against ASAM/InterQual criteria
4.Submit via FHIR R4 (CMS-0057) or payer portal
5.Track decision via daily portal polling
6.Route approvals to provider; route denials to clinician review
✓
Routine PAs decision in 24 hours instead of 3–5 days, with audit-ready clinical justification.
Use Case 2
Concurrent Review & Continued Stay
Trigger: Inpatient or partial-hospitalization authorization approaching expiration
1.Pull current clinical status from EHR
2.Compare against continued-stay criteria (InterQual BH, ASAM)
3.Recommend continued stay, step-down, or discharge
4.Draft reauthorization packet for cases meeting criteria
5.Route to medical director for review and sign-off
6.Submit reauth to vendor or payer
✓
Continued-stay decisions made on clinical merit with consistent criteria and clinician oversight.
Use Case 3
Denial Review & Peer-to-Peer (HITL)
Trigger: Payer or BH carve-out vendor denies authorization
1.Parse denial rationale and reviewer credentials
2.Flag procedural defects (e.g., non-BH reviewer under SB 1120)
3.Pull supporting clinical evidence and criteria mapping
4.Draft appeal with procedural and clinical arguments
5.Coordinate peer-to-peer scheduling between physicians
6.Route appeal package to medical director for finalization (mandatory HITL)
✓
Denials reviewed by qualified BH clinician; appeals carry both procedural and clinical merit.
Integrations
FHIR R4 / CMS-0057 PA APIs
BH Carve-Out Vendor Portals (Magellan, Optum BH, Carelon)
EHR Clinical Data (Epic, Cerner, athenahealth)
Medical Necessity Criteria (InterQual, MCG, ASAM)
Approval Workflow (RequestApproval)
Peer-to-Peer Scheduling
Industries
healthcare
See It In Action
A sample conversation with this agent
PA request just came in for partial hospitalization, patient with major depression and SI.
Pulling the request. Service: PHP (REV 0912), 10-day initial authorization. Patient: 34F, MDD with active suicidal ideation, recent IOP completion without stabilization. Provider Dr. Chen, NPI verified, in-network with the plan. Determining PA requirement: yes, plan requires PA for all PHP. Assembling the clinical packet—H&P, last 30 days of notes, BH carve-out vendor (Optum BH 87726) is the adjudication owner. Drafting medical necessity narrative against ASAM Level 2.5 criteria. FHIR R4 bundle ready for CMS-0057 submission once narrative passes my review.
The plan denied James Patel's PHP—I want to push back.
Pulling the denial. Reason cited: 'criteria for PHP not met, recommend IOP.' Their reviewer was a family practitioner. Under California SB 1120, BH denial review requires a qualified BH specialist. That's a procedural defect I can flag in the appeal. On clinical merit: James has documented failure of IOP twice in 90 days, current PHQ-9 of 22, and CSSRS-positive ideation last week. His criteria meet ASAM 2.5 and InterQual BH-Adult PHP. I'll draft the appeal with the procedural and clinical arguments together and route for medical director review. I do not finalize denials autonomously—Phase 9 is HITL by design.
Run the concurrent review on the inpatient psych authorizations expiring this week.
12 inpatient psych authorizations expiring within 7 days. For each I'm pulling current clinical status from the most recent progress note, comparing against discharge readiness criteria, and assessing continued stay justification under InterQual BH-Adult Inpatient. Results: 7 meet continued stay criteria with documented active treatment, 3 appear ready for step-down to PHP/IOP (recommending discharge planning rather than reauth), 2 need clinician review—charts show conflicting acuity signals. Drafting reauth packets for the 7 and step-down recommendations for the others. Nothing leaves until medical director sign-off.