Smart Data Framework: Prior Authorization and Claims Matching

Prior authorization and claims information frequently arrive through separate systems, formats, and workflows. This fragmentation creates unnecessary reconciliation work, increases the risk of preventable denials, and delays resolution for health plans, providers, and members.

Everforth Apex is a services partner with proven experience applying AWS AI to complex payer document workflows. Our team delivered a serverless provider-contract intelligence solution built with AWS Bedrock, Lambda, and DynamoDB for a Fortune 500 health insurer. We apply that same delivery discipline to prior authorization and claims matching engagements.

Using our Smart Data Framework, the solution transforms authorization documents and claims materials into structured, comparable information. It extracts relevant details - including patient, provider, service, date, procedure, authorization, and coverage information - and applies configurable matching rules developed by our consultants alongside your operations team.

Key capabilities:

• Extracts and structures data from unstructured authorization and claims documents
• Identifies aligned records and surfaces discrepancies, incomplete documentation, missing authorizations, or inconsistent information
• Routes straightforward matches through established workflows while directing complex exceptions to qualified staff
• Connects supporting evidence to each match or discrepancy so reviewers understand the basis for results

Our engagement follows five phases:

1. Discovery - We assess your current authorization and claims workflows, document formats, system integrations, and operational pain points. Deliverable: Workflow Assessment Report.
2. Solution Design - We define matching rules with your operations and compliance leaders and architect the AWS solution. Deliverable: Signed Solution Design Document.
3. Build - We develop and configure the extraction, matching, and exception-routing components on AWS. Deliverable: Deployed Solution in staging environment.
4. Integration Testing - We validate the solution against your systems and data. Deliverable: Test Results and Go-Live Readiness Report.
5. Hypercare - Post-launch support including rule tuning and issue resolution. Deliverable: Ongoing optimization and knowledge transfer.

Buyers should be prepared to provide:

• Sample prior authorization documents and claims files during discovery
• Access to operations and compliance subject matter experts
• System access or data extracts from relevant claims and authorization platforms

The engagement covers matching rule configuration and integration with existing workflows. Full adjudication workflow redesign, clinical decision support, and claims payment processing are outside scope unless explicitly agreed during discovery.

The solution is built on AWS services that support HIPAA-eligible workloads. Human oversight and existing clinical, payment, coding, and compliance controls remain part of the adjudication process. Data handling follows AWS security best practices including encryption at rest and in transit.

Engagements are scoped during discovery and structured as fixed-fee or milestone-based arrangements depending on complexity. Contact us to schedule a Discovery Call and receive a tailored proposal for your environment.

Operations teams spend less time searching across systems and more time resolving cases that require expertise. The result is faster reconciliation, fewer manual errors, improved exception visibility, and a more predictable experience for health plans, providers, and members.