Prior Authorization Automation
We gather the information for prior authorization requests, fill payer forms, and submit the supporting documents. The automation checks for updates and saves them in your systems. Your team handles missing information and cases that need review.
Illustration of a prior authorization run. Three new orders are in the queue. For two, the automation pulls the order and insurance details, attaches the clinical note, fills the payer form, submits the request and saves the confirmation number and time. The third is missing the required clinical note, so it goes to staff review before submission. The example ends with 2 submitted and 1 needing a clinical note. No payer decision is shown.
How PTCoA automated prior authorization submissions
PTCoA's team prepared requests across several payer portals. We built automation to transfer order details, submit requests, and save confirmations. A separate follow-up process checks for payer updates and sends cases needing attention to staff.
Measured results
Results from PTCoA's project. Submission time is separate from the time a payer takes to decide.
A genetic diagnostic lab cut handling time from 8–12 minutes to under 1 minute by moving order details and documents from its lab system into an authorization portal. Read the lab case study Explore our laboratory automation workflows for related document and payer-portal tasks.
The tasks behind a prior authorization request.
Each request involves gathering information, preparing documents, submitting a form, and checking for an answer. These are the tasks we automate.
-
01Gather
Pull the information already recorded for the order.
- Find new orders or requests in your work queue.
- Pull patient, insurance, provider, and service details from your systems.
- Collect the available clinical notes and other required documents.
-
02Prepare
Check the request against the payer's requirements.
- Check authorization and document requirements where the payer makes them available.
- Fill the required fields using the information on the order.
- Flag missing documents, conflicting details, or questions needing clinical review.
-
03Submit
Send the request and keep its confirmation.
- Submit through the supported payer connection or portal.
- Attach the required documents for the right patient and order.
- Save the confirmation number, submitted packet, and submission time.
-
04Follow up
Check what changed and record the answer.
- Check open requests on an agreed schedule.
- Save payer decisions, authorization details, and validity dates when returned.
- Send information requests, denials, and unresolved cases to your staff.
We set up the workflow for your systems, payers, and rules. Your team handles the cases that need a person.
The payer decides whether to approve a request. An approval does not guarantee that the claim will be paid.
Prior authorization automation usually pays off when most of these are true.
- Your team prepares many authorization requests each week.
- Staff copy order details and upload the same documents into payer portals.
- Someone checks pending requests repeatedly for updates.
- Most requests follow known steps, and you know which cases need clinical review.
What affects your savings
- How many requests you submit each month
- How long preparation, submission, and follow-up take by hand
- Which payer connections and portals are available
- How often documents are missing or clinical review is needed
- What it costs to build and maintain
The return is different for every organization. Schedule a call and we'll give you a quick, honest estimate of whether it's worth it for yours.
Schedule a callThe automation moves requests between your systems and payer portals.
Your staff keep using the systems they know. We use a direct connection where one is available, or UiPath and Python to work with portals and desktop apps. AI can read documents and payer messages. Questions that need clinical judgment go to your team.
Example of the automation between three places. It reads new orders from the EHR or lab system, enters the patient details and attachments in the payer portal, submits the request and saves the confirmation back to the order. The second request stays pending. The third order is missing its clinical note, so it goes to the staff review queue before submission. Later, a payer update approves the first request, and the authorization number and dates are saved.
Monitored and maintained by us. We check the runs and update the workflow when payer portals or your systems change.
Eligibility checks and claim submission are separate workflows. Authorization appeals can be added where the process and review rules are clear.
Patient data (PHI)
What happens to your patient data
Your data is safe.
- Where it runs
- On a machine you own: usually a virtual machine on your side, or your own AWS or Azure account.
- What we store
- We don't store patient data. The automation reads it, uses it and writes the result back. In the rare case PHI has to be in transaction data, it's encrypted.
- Who can access it
- Only the developer who builds and maintains the automation. On your machine, you decide who else gets access.
- What we sign
- A BAA before we see any patient data. AI runs on AWS, Azure or Google under BAAs, and your data isn't used to train models.
Is automating your prior authorization work worth it?
Book a 30-minute call with Karl, our CTO. If you'd rather write, send us a message.
Walk me through how your team prepares and follows up on authorization requests. Within the first 15 minutes, we can usually tell whether automation makes sense. We'll discuss the work involved and what we'd need to estimate the cost.
Karl