AI Prior Auth — Command Center

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Processing History

Date	Filename	Procedure	Readiness	Denial Risk	Time
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Total Agents

Active in pipeline

Extraction

Reader + Core agents

Policy & Matching

Matcher + Payer agents

Docs Processed

Total referrals

Appeal & Evidence

Appeal + P2P + Evidence

Validation

Quality + Cross-check

Accuracy

Audit + Regression

Oversight

Arch + Security + Accuracy

Watchdog

Problem monitors

Problem Watchdog Map

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Reader Agents — Document Extraction

Core Pipeline Agents

Policy Matcher Agents — 4-Layer Verification

Payer Policy Agents

Interpretation & Validation Agents

Appeal, Evidence & Medical Necessity Agents

Prediction, Workflow & Generation Agents

Lifecycle, Eligibility & Urgency Agents

Accuracy Enforcement Agents — 99% Target

Oversight Agents — Architecture, Security, Accuracy

Analytics & Monitoring Agents

Watchdog Agents — Problem Prevention

V2 System Architecture

  REFERRAL PDF
       |
       v
  [Document Loader] -------- PDF to Text + OCR Fallback + Redaction Detection
       |
  [Clinical Interpretation] - Abbreviation expansion, OCR correction, date normalization
       |
       |  +----- PARALLEL EXTRACTION (8 Reader Agents) -----+
       |  |                                                   |
       v  v                                                   |
  [Admin/Eligibility Reader]   [Symptoms Reader]              |
  [Medical History Reader]     [Medications Reader]           |
  [Prior Testing Reader]       [Labs Reader]                  |
  [Vitals/Exam Reader]         [Referral Order Reader]        |
       |  |                                                   |
       |  +---------------------------------------------------+
       |                    |
       |         [Extraction Audit Agent] -- validates ranges, dates, formats
       |         [Cross-Validation Agent] -- reader contradictions
       |         [Quality Gate Agent] ------ documentation completeness
       v
  [Procedure Classifier] ------ Maps to cardiology procedure (Claude API)
       |
       v
  [Eligibility Verification] -- member ID format, plan type, PCP referral
  [Urgent Detection] ---------- 4 urgency levels, 13 clinical triggers
       |
       v
  +---- 4-LAYER POLICY MATCHING (5 Payer Agents) ----------+
  |  BCBSTX | Aetna | UHC | Cigna | Medicare               |
  |                                                          |
  | [Layer 1: Eligibility] ---- admin, referral, signed order|
  | [Layer 2: Clinical Doc] --- symptoms, vitals, labs       |
  | [Layer 3: Medical Necessity] -- ICD-10, AAD, GDMT       |
  | [Layer 4: Procedure-Specific] -- LVEF, NYHA, heart team |
  |                                                          |
  +----------------------------------------------------------+
       |                    |
       |         [Matcher Audit Agent] ----- false positive/negative detection
       |         [Policy Validation Agent] -- policy JSON integrity
       v
  [Readiness Aggregator] ------ GREEN / YELLOW / RED
  [Denial Prediction Agent] --- risk scoring, 19+ denial triggers
  [Next Steps Agent] ---------- prioritized action items
       |
       v
  AUTHORIZATION PACKAGE -------- Ready for payer submission
       |
       v  (if denied)
  [Appeal Letter Generator] --- clinical evidence + guideline citations
  [P2P Call Prep Agent] ------- physician talking points
  [Clinical Evidence Agent] --- landmark trials, ACC/AHA, LCD precedent
  [Medical Necessity Agent] --- patient-specific necessity arguments
  [Auth Status Tracker] ------- 18-state lifecycle tracking
       |
       v
  [Patient Communication] ----- plain-language letters (6th-grade level)

  OVERSIGHT:   [Architecture Review] [Security Review] [Accuracy Validation]
  ACCURACY:    [Extraction Audit] [Matcher Audit] [Regression Gate] [Policy Validation]
  WATCHDOGS:   [OCR Quality] [Reader Consistency] [Policy Match] [Procedures] [Redaction]
  ANALYTICS:   [Denial Analytics] [Policy Monitor] [Industry ROI]

Estimated Hours Saved

Based on documents processed

Estimated Dollar Savings

Staff time + denial prevention + clawback savings

Savings Breakdown

Staff Time Savings

Auth coordinators spend avg 45 min per PA manually. Our AI processes in under 1 minute.

Denial Prevention

Pre-submission checks catch missing items before they become denials. Each denied claim costs $118 to rework.

Clawback Prevention

Industry avg 3.5% clawback rate. Proper PA documentation prevents post-payment recoupment averaging $2,800/incident.

Rework Reduction

22% of PAs require resubmission. Our completeness checks reduce rework by 65%.

P2P Call Prep Savings

AI generates physician P2P prep in 1 min vs 30+ min manual preparation. Valued at physician hourly rate.

Appeal Letter Savings

AI drafts structured appeal letters with guideline citations in 2 min vs 45 min manual drafting.

Per-Document Value

Minutes Saved Per Document

vs. industry average of 45 minutes manual processing

Dollar Value Per Document

Including time savings, denial prevention, and clawback avoidance

Industry Benchmarks vs. AI Prior Auth

Time & Efficiency

PA Processing Time 45 min → <1 min

Appeal Letter Drafting 45 min → 2 min

P2P Call Preparation 30 min → 1 min

Days to PA Approval 14 days → ~3 days

Staff FTEs per 500 PAs/mo 2.5 FTE → 0.5 FTE

Cost & Revenue Impact

Initial Denial Rate 17% → ~10%

PA Rework Rate 22% → ~8%

Clawback Rate 3.5% → ~1.4%

Cost per Denied Claim $118

Avg Clawback Amount $2,800

Annual Savings Projections

Monthly PA Volume	Annual Hours Saved	Staff Savings	Denial Savings	Clawback Savings	Total Annual Savings
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Data Sources: AMA Prior Authorization Physician Survey (2023), CAQH Index (2023), MGMA DataDive Cost and Revenue, Experian Health State of Claims Report, ACC Cardiology Practice Benchmark Report. Clawback data from HFMA Revenue Cycle Benchmarking Report. Staff rates from Bureau of Labor Statistics (Medical Secretaries & Admin Assistants, 2024).

Total in Pipeline

Active cases

Need Appeal Letter

Awaiting generation

Need P2P Prep

Calls to prepare

Awaiting Decision

Submitted / in review

Available Agents

Ready to assist

Denial & Appeal Cases

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Agents Helping

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