Prior Authorization Agent

Category: Clinical Operations · Voice agent: PA Specialist (agent type.PA_SPECIALIST)

The Prior Authorization Agent drives the PA lifecycle through a 17-state workflow with payer-specific rules and multi-channel submission. Voice agent The PA Specialist handles outbound peer-to-peer and status calls.

Workflow states

Payer rules

stores rules for 10 payers (PayerId enum): CARELON_ANTHEM, OPTUM_BH, MAGELLAN, EVERNORTH, UNITED_HEALTHCARE, AETNA, CIGNA, BLUE_CROSS, MEDICAID, MEDICARE. returns:

Field	Values
Recommendation	`AUTO_APPROVE`, `LIKELY_APPROVE`, `NEEDS_REVIEW`, `LIKELY_DENY`
Match result	`ALL_MET`, `MOSTLY_MET`, `PARTIALLY_MET`, `NOT_MET`

Document generators

Document type	Producer
`MEDICAL_NECESSITY`
`CLINICAL_SUMMARY`
`TREATMENT_PLAN`
`ASSESSMENT`
`PROGRESS_NOTE`
`DISCHARGE_SUMMARY`
X-12 EDI 278 (PA request)

Submission channels Channel priority :

Endpoints

Method	Path (Backend)	Path (AI Services)
POST	`/api/prior-auth/evaluate`	`/api/pa/evaluate`
POST	`/api/prior-auth/evaluate/quick`	`/api/pa/evaluate/quick`
POST	`/api/prior-auth/requests`	`/api/pa/requests`
GET	`/api/prior-auth/requests/{id}`	`/api/pa/requests/{id}`
POST	`/api/prior-auth/requests/{id}/submit`	`/api/pa/requests/{id}/submit`
POST	`/api/prior-auth/requests/{id}/appeal`	`/api/pa/requests/{id}/appeal`
GET	`/api/prior-auth/payers`	`/api/pa/payers`
GET	`/api/prior-auth/payers/{id}/rules`	`/api/pa/payers/{id}/rules`
POST	`/api/prior-auth/documents/generate`	`/api/pa/documents/generate`
GET	`/api/prior-auth/channels`	`/api/pa/channels`
POST	`/api/prior-auth/webhooks/payer-response`	`/api/pa/webhooks/status`
POST	—	`/api/pa/coding-suggest`

Real-time coding suggestion

runs during intake to flag PA-required codes. Detected CPT: 90832, 90834, 90837, 99213, 99214, 99215, 96127. Detected ICD-10: F32.1, F33.1, F41.1, F43.10, F11.20. Each suggestion includes pa_required, pa_urgency, payer_policy_url, evidence_excerpt.

Composable experts

Expert	Role
PubMed Expert	Peer-reviewed evidence
Payer Policy Expert	Carrier-specific rules + formulary
Clinical Scoring Expert	PHQ-9, GAD-7, validated scores
Medical Coding Expert	ICD-10 + procedure code validation

Compliance guarantees

Every PA letter carries explicit citations to chart and payer policy. - Letters are submitted only after clinician approval. - Payer webhooks are verified with per-payer HMAC secrets.

Quickstart

Generate your first PA letter.

PA API

REST surface.

Denial Appeals

Appeal lifecycle.

Eligibility

Pre-visit benefits.

​Workflow states

​Payer rules

​Document generators

​Submission channels Channel priority :

​Endpoints

​Real-time coding suggestion

​Composable experts

​Compliance guarantees

​Related

Quickstart

PA API

Denial Appeals

Eligibility

Workflow states

Payer rules

Document generators

Submission channels Channel priority :

Endpoints

Real-time coding suggestion

Composable experts

Compliance guarantees

Related