Use Case 1
Standard PA Request Processing
Trigger: Incoming authorization request from provider
1.Verify provider credentials and Medicare enrollment status
2.Extract clinical indication and supporting documentation
3.Match request against applicable NCD/LCD coverage criteria
4.Check historical denial patterns for similar requests
5.Generate decision recommendation with evidence citations
6.Route to human reviewer with audit packet
7.Issue authorization number and notify requesting provider
✓
Most standard requests resolve in under an hour with full documentation; complex cases reach human reviewers with pre-assembled evidence packets.
Use Case 2
Appeals-Resistant Decision Documentation
Trigger: Complex or high-cost service request
1.Assemble complete clinical picture including chart history
2.Cite specific NCD/LCD sections and criteria met or not met
3.Document all evidence reviewed and decision logic
4.Flag items requiring specialty medical review
5.Produce audit-ready decision packet
✓
Every denial or partial approval carries defensible documentation that withstands appeal.
Integrations
Payer Utilization Management Platform
CMS NCD / Local LCD Database
NPPES NPI Registry
Provider EHR Integration (HL7/FHIR)
Claims System
Audit & Compliance Module
Industries
healthcare
See It In Action
A sample conversation with this agent
Process the PA request for Jennifer Torres—MRI lumbar spine.
Pulling the request. Provider Dr. Kim (NPI verified, active Medicare enrollment). Clinical indication: persistent low back pain with radicular symptoms, 6+ weeks duration, conservative therapy (PT x8 weeks, NSAIDs) documented and failed. Checking against CMS NCD 220.2 and regional LCD L33950: MRI is covered when conservative therapy has failed and radicular symptoms are present. All criteria met. Generating approval with authorization number, routing for payer medical director review as the final human gate. Decision packet will include full audit trail.
Why did you route this one for review instead of auto-approving?
Patient has two red flags I can't resolve autonomously: (1) the conservative therapy documentation shows a 3-week PT course, not the 6-week minimum the LCD requires, and (2) there's an inconsistency between the ordering provider's clinical note and the submitted diagnosis codes. Either could be a documentation issue or a genuine coverage question. I've packaged both flags with the clinical evidence and routed to the medical director. I don't make denial decisions autonomously.
How many auths are pending review right now and what's the SLA?
32 pending: 8 auto-approvals awaiting final sign-off (target <1hr), 19 routed for medical director review (target <24hr), 5 escalated for specialty consultation (target <72hr). Three are within 2 hours of SLA breach—I've sent Slack alerts to the assigned reviewers. Average decision time this week is 4.2 hours, down from 3.8 days pre-automation.