AI-Assisted Prior Authorization for a Specialty Practice
An assistant that reads the payer's criteria and the patient chart, assembles the authorization packet with the supporting evidence, and leaves the submission decision to staff.
Each prior authorization took a coordinator 35 to 45 minutes of chart reading and form filling. Backlogs delayed treatment, and missing documentation caused avoidable denials.
The approach.
- 01Collected payer criteria for the practice's top procedures into a structured rules library.
- 02Pulled relevant notes, labs and imaging reports from the EHR for each request.
- 03Generated the packet with every criterion linked to the chart evidence that supports it.
- 04Flagged missing evidence before submission, so staff could request it first.
- 05Kept submission manual: a coordinator reviews and sends every packet.
Claude matches each payer criterion to evidence in the chart, drafts the medical-necessity summary with citations to the source notes, and lists what is missing.
How we measure it.
Time is logged in the work queue. Denial reasons come from payer responses, compared against the previous quarter for the same procedures. Turnaround is measured from order to submission.
Before you ask.
No. Beyond Technologies designs it so a coordinator reviews every packet and submits it. The AI assembles and cites; people decide.
Payer criteria live in a rules library the practice can update. When a payer changes its policy, staff edit the rule rather than retrain anything.
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