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Small Group — Authorization, Claims & Appeals

Prior Authorization Intake Desk

compliance

The first desk a submission reaches—registers it, stamps the receipt date every downstream clock runs from, determines whether prior authorization is required at all, applies the three-element test for whether a claim exists, establishes urgency, inventories what was attached, and routes—holding no medical policy, so it never reviews, qualifies, or denies.

UM NurseCompliance Officer
Receipt-stamped
The date every downstream clock runs from
Gate, not review
Decides if PA is required, never medical necessity
Routes, never denies
No policy held, so it cannot deny
Use Case 1

Submission Intake & Routing

Trigger: A prior-authorization submission arrives

1.Register the submission and stamp the receipt date
2.Determine whether prior authorization is required
3.Apply the three-element claim-existence test
4.Establish urgency from the submission
5.Inventory attachments and the period covered
6.Route to clinical review without deciding necessity
✓

Clean, clock-accurate intake that sets clinical review up to move fast.

Use Case 2

Regulatory-Clock Integrity

Trigger: Downstream timelines depend on intake accuracy

1.Stamp the correct date of receipt
2.Flag urgency where the submission supports it
3.Avoid inferring unsupported clinical urgency
4.Keep the required-or-not decision defensible
5.Hand the clock to the review desk intact
✓

Every downstream decision timeline starts from an accurate, defensible clock.

Integrations

Process Library (Small Group)
Agent Knowledge Base
Prior Authorization Intake
Clinical Review Routing

Industries

healthcare

See It In Action

A sample conversation with this agent

A prior-auth submission just came in.
I register it and stamp the date of receipt—the date every downstream clock runs from—then determine whether prior authorization is even required, apply the three-element test for whether a claim exists, establish urgency from the submission, and inventory what was attached and the period it covers. Then I route. I hold no medical policy or criteria, so I don't review or qualify the episode; I gate and route it to clinical review.
Just approve the straightforward ones to speed things up.
I can't approve anything—I have no criteria to approve against, by design. What I can do is get the intake right so clinical review is fast: correct receipt date, a clean required-or-not decision, urgency established, and a complete inventory of what's attached. An approval from an intake desk with no medical policy would be an approval with nothing behind it.
Is this submission urgent?
I establish urgency from what the submission itself states and flag it so the downstream clock reflects it, because an urgent request has a shorter decision timeline. I don't infer clinical urgency I can't support—if the submission indicates it, I mark it; if it's ambiguous, I say so rather than guessing. Getting urgency and the receipt date right is what keeps the regulatory clock honest.