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Documentation Index

Fetch the complete documentation index at: https://docs.medera.info/llms.txt

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Category: Clinical Operations  ·  Voice agent: Taylor (AgentType.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 Taylor handles outbound peer-to-peer and status calls.

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Workflow states (WorkflowState enum)

PA_INITIATED
  → PA_CRITERIA_EVALUATION → PA_CRITERIA_EVALUATED
  → PA_DOCUMENTS_PENDING → PA_DOCUMENTS_READY
  → PA_PENDING_SUBMISSION → PA_SUBMITTED
  → PA_IN_REVIEW
      ├→ PA_PENDED → PA_INFO_REQUESTED
      ├→ PA_APPROVED | PA_PARTIALLY_APPROVED
      └→ PA_DENIED
          → PA_APPEAL_DRAFT → PA_APPEAL_SUBMITTED
              → PA_APPEAL_APPROVED | PA_APPEAL_DENIED
          → PA_P2P_SCHEDULED → PA_P2P_COMPLETED

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Payer rules

payer_rules_repository.py stores rules for at least 10 payers via PayerId: CARELON_ANTHEM, OPTUM_BH, MAGELLAN, EVERNORTH, UNITED_HEALTHCARE, AETNA, CIGNA, BLUE_CROSS, MEDICAID, MEDICARE. rule_evaluator.py returns:
FieldValues
RecommendationAUTO_APPROVE, LIKELY_APPROVE, NEEDS_REVIEW, LIKELY_DENY
Match resultALL_MET, MOSTLY_MET, PARTIALLY_MET, NOT_MET

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Document generators

Document typeProducer
MEDICAL_NECESSITYnarrative_service.py
CLINICAL_SUMMARYnarrative_service.py
TREATMENT_PLANnarrative_service.py
ASSESSMENTnarrative_service.py
PROGRESS_NOTEnarrative_service.py
DISCHARGE_SUMMARYnarrative_service.py
X-12 EDI 278 (PA request)x12_builder.py

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Submission channels

Channel priority (submission_router.py): 
EPA_API → CLEARINGHOUSE → PORTAL → FAX → MANUAL

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Endpoints

MethodPath (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

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Real-time coding suggestion

The intake pipeline calls realtime_coding_service.py to detect codes likely to require PA during the call. Detected CPT codes include 90832, 90834, 90837 (psychotherapy), 99213, 99214, 99215 (E/M), and 96127 (assessment); ICD-10: F32.1, F33.1, F41.1, F43.10, F11.20. Each suggestion includes pa_required, pa_urgency, payer_policy_url, and evidence_excerpt.

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Composable experts

ExpertRole
PubMed ExpertPeer-reviewed evidence
Payer Policy ExpertCarrier-specific PA rules + formulary
Clinical Scoring ExpertPHQ-9, GAD-7, validated scores
Medical Coding ExpertICD-10 + procedure code validation

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Compliance guarantees

  • Every PA letter carries explicit citations to chart and payer policy
  • Letters are submitted only after clinician approval
  • Webhooks from payers 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.