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Use Case : HEALTHCARE

AI-Powered
Patient Access & Prior Authorization

Connect registration, referral and order capture, eligibility verification, payer policy checks, clinical evidence and staff review to accelerate authorization and patient access.

Business challenge

Patient Access Stalls at Handoffs Between Registration, Clinical Documentation and Payer Requirements

Prior authorization requires patient demographics, insurance eligibility, referral orders, clinical notes, payer criteria and appointment context to be assembled accurately and on time. Manual portal entry, repeated document searches and status follow-up consume staff capacity, delay scheduling and increase the risk of incomplete submissions and avoidable denials.

Common challenges include:

  • Multi-step patient intake: Registration and scheduling information must be captured before downstream eligibility and authorization checks can begin.
  • Referral and order handling: Referral or order information needs to be captured accurately and linked to the patient access case.
  • Eligibility verification: Insurance and patient data need to be checked before the service pathway can progress.
  • Prior-authorization complexity: Payer rules need to be applied against the referral and available clinical context to determine the required next step.
  • Staff follow-up workload: Access teams need a clear case summary before escalating exceptions, updating appointments and communicating reminders.

Payer-Aware Prior Authorization Orchestration with Clinical Evidence Assembly and Human Escalation

The workflow captures referral and order information, verifies coverage, retrieves clinical evidence, evaluates payer rules and prepares a structured case summary. Routine, well-documented cases can be advanced automatically, while clinical or policy exceptions are routed to staff for review before submission, escalation or scheduling.

The solution uses:

  • Patient intake and scheduling: Capture patient and appointment context at the start of the access workflow.
  • Referral / order capture: Collect and structure referral or order information through intelligent document processing.
  • Eligibility verification: Apply defined checks against insurance and patient information before service confirmation.
  • Prior-authorization rule check: Evaluate the case against payer requirements to determine whether additional authorization steps are needed.
  • AI-generated case summary: Present patient, referral, eligibility and authorization context in a concise staff-ready brief.
  • Staff review and escalation: Keep access exceptions, escalation and final administrative decisions under human review.
  • Appointment and reminder update: Record the confirmed status and update the appointment / reminder workflow in EHR / RCM.

Smarter invoice processing solution

Quantified Evidence for Prior-Authorization Automation

Results

50–75% manual PA tasks automatable

McKinsey analysis suggests AI-enabled prior authorization can automate 50–75% of manual tasks.

60–80% operational-efficiency improvement

Deloitte identifies this target range for AI-enabled prior-authorization workflows.

4–6% reduction in avoidable denials

Deloitte identifies a 4–6% target reduction in denials caused by missing or incomplete information.

From Manual Portal Chasing to
Exception-Based Patient Access

Patient-access work shifts from repetitive data collection and status checking toward exception management. Automation assembles the authorization packet and applies payer logic, while staff focus on missing evidence, medical necessity, peer-to-peer review and cases that require judgment.

    The workflow

    How AI-Powered Patient Access & Prior Authorization Works

    The workflow connects patient intake, referral capture, eligibility, payer-rule evaluation, AI-assisted case summarization, staff review and EHR/RCM scheduling update.

    01 INTAKE

    Patient Intake & Scheduling

    Patient and appointment information enters the access workflow to establish the case context.

    • Patient demographics
    • Requested service / appointment
    • Available scheduling context

    Technology / System: Patient Intake / Scheduling

    02 CAPTURE

    Referral / Order Capture

    Referral and order information is collected and structured for access processing.

    • Referral order
    • Supporting clinical notes
    • Relevant service or provider details

    Technology / System: IDP / Referral + Order Capture

    03 VERIFY

    Eligibility Verification

    Patient and insurance information is checked against defined eligibility requirements.

    • Insurance data
    • Patient identity / demographic context
    • Eligibility conditions

    Technology / System: Eligibility API / Coverage Verification

    04 CHECK

    Prior Auth Rule Check

    The referral and case context are evaluated against payer requirements to determine the authorization path.

    • Payer rules
    • Referral / order context
    • Available clinical information

    Technology / System: Payer Policy Engine / Rules

    05 SUMMARIZE

    GenAI Case Summary

    Generative AI prepares a concise access summary covering intake, eligibility and prior-authorization context.

    • Patient and appointment summary
    • Eligibility result
    • Authorization status and key exception context

    TTechnology / System: GenAI Authorization Case Summary

    06 REVIEW

    Staff Review & Escalation

    Patient-access staff review the case and resolve or escalate exceptions before confirming the next action.

    • Confirm access path
    • Escalate authorization or eligibility exception
    • Request additional information where required

    Technology / System: Staff / Clinical Review

    07 UPDATE

    Appointment & Reminder Update

    The confirmed case status is reflected in the patient-access systems and downstream appointment communication.

    • Appointment status
    • Reminder / communication update
    • Access or authorization recordd

    Technology / System: EHR / RCM / Scheduling Update