Prior authorization automation software

Automated prior authorization request submission across payer portals and EDI channels. For payers that accept X12 278 transactions, requests are formatted and submitted via a clearinghouse connection to Change Healthcare, Availity, or Waystar, with the payer's companion guide rules applied during transaction generation. For payers that require portal-based submission, UiPath or Microsoft Power Automate handles the portal navigation, field population, and document upload sequence, recording each interaction in the audit log.

Patient demographics, insurance identifiers, requesting provider NPI, and servicing facility NPI are sourced from your EHR via FHIR R4 Patient and Coverage resources where available, or from HL7 ADT messages for EHR systems that predate FHIR. Procedure codes (CPT/HCPCS) and diagnosis codes (ICD-10-CM) are pulled from the order or referral record. Supporting clinical documentation is attached automatically when the file is linked to the encounter. Each submission generates a reference number and timestamp in the case record so staff can see what was submitted, when, and through which channel, without opening the payer portal.

A rules engine that encodes each payer's clinical criteria requirements and maps them to the correct documentation package for each procedure and diagnosis combination. Payer clinical policy guidelines change several times per year, the rules engine version-controls each policy set so a policy update doesn't silently break in-flight requests. When a payer updates their coverage policy for a procedure, the updated rule set is applied to new requests while historical requests retain the policy version that was in effect at submission time.

The rules engine handles the differences that cause manual rework: some payers require a peer-to-peer review letter for certain CPT codes, others accept the clinical note directly; some require step therapy documentation before approving a specialty medication, others require the prescribing physician's attestation. These aren't edge cases, they're the standard operational differences across UnitedHealthcare, Aetna, BCBS plans, Cigna, and Humana that your staff currently navigates from memory. The rules engine encodes them explicitly so the correct documentation package is assembled without staff knowing which payer requires what.

Status polling against payer portals and X12 278/279 transaction responses on a defined schedule, typically every four hours during business hours, so staff can see PA status in the system without calling the payer line. X12 279 response transactions are parsed to extract approval, denial, pend, or additional information required status updates and write them back to the PA case record. Portal-based status checks use the same RPA session used for submission, navigating to the case status screen and extracting the current status without manual staff involvement.

Status transitions trigger workflow events: approval triggers notification to the scheduling team and updates the encounter authorization record in the EHR; a pend or additional information request triggers a task assigned to the clinical team with the specific information the payer is requesting; a denial triggers the denial management workflow. Time-sensitive requests, same-day procedures, inpatient admissions, get a separate escalation path with more frequent polling and immediate notification to the clinical lead when authorization isn't received within the expected window.

Automated matching of the patient's clinical record against the payer's clinical criteria for the requested procedure or medication before the PA request is submitted. For EHRs that expose FHIR R4 APIs, the matching engine reads Condition (ICD-10-CM diagnoses), Observation (lab results and vitals), MedicationRequest (current and prior medications), and DocumentReference (clinical notes) resources and checks them against the payer's criteria set. This catches missing documentation before submission rather than after denial.

For CRD (Coverage Requirements Discovery) and DTR (Documentation Templates and Rules) implementations per the Da Vinci implementation guides, supported by Epic and Cerner environments on recent versions, criteria matching is embedded in the clinician's ordering workflow via CDS Hooks. The system surfaces the payer's requirements at the point of order entry, allowing the ordering provider to confirm documentation is in place before the order is placed. For EHR environments that don't yet support CRD/DTR, the standalone criteria matcher runs as part of the pre-submission workflow rather than at order entry.

When a PA request is denied, the denial reason code from the X12 279 response or portal screen is mapped to a plain-language explanation and the standard appeal pathway for that payer and denial type. Common denial reasons, missing clinical documentation, criteria not met, incorrect procedure code, step therapy not documented, each have a defined remediation workflow in the system so the person handling the denial knows what's needed without interpreting the payer's denial code.

Appeal letter generation pulls from payer-specific templates pre-populated with patient data, clinical documentation, and the denial reason so the appeal writer starts from a complete draft rather than a blank document. Peer-to-peer review scheduling, required by many commercial payers for complex medical necessity denials, is tracked in the system with the payer's scheduling deadline and the case assigned to the requesting physician. Follow-up task queues track each appeal against the payer's appeal filing deadline so nothing ages past the timeframe. Denial trend reporting by payer, denial code, procedure code, and service line gives the clinical team the data to identify whether a specific payer is consistently applying criteria differently from their published policy.

Bidirectional EHR integration that pulls clinical data into the PA workflow and writes authorization results back to the patient record. FHIR R4 integration handles Epic (via App Orchard), Cerner Millennium, and Athenahealth, Patient, Coverage, Condition, Observation, MedicationRequest, DocumentReference, and ServiceRequest resources cover the clinical and insurance data the PA workflow needs. SMART on FHIR OAuth 2.0 handles authorization for FHIR-enabled environments.

For EHR systems running on HL7 v2 interfaces, the integration engine (Mirth Connect or Azure Health Data Services) parses ADT, ORM, and ORU message types to extract the equivalent clinical data. Authorization results, approval number, approved dates, approved units, payer reference number, are written back to the EHR as FHIR R4 Coverage resources or via HL7 interface depending on the EHR's write API support. This means the authorization number lives in the patient's EHR record and flows automatically to the claim at billing rather than being transcribed manually by the billing team.