Sold by: HCLTech
PriorAuth is a transformative Agentic AI solution that automates and revolutionizes the entire Prior Authorization verification process for insurance payers. By leveraging Agentic AI, natural language processing, and machine learning, our solution drastically reduces manual effort, increases accuracy, gets aligned with CMS Interoperability Regulations of 2027 and accelerates document processing by reducing processing time from hours to minutes.
Overview
Our cutting-edge solution leverages Amazon Bedrock Agents to revolutionize Prior Authorization (PA) processing through an advanced Agentic AI architecture. Leveraging sophisticated multi-agent collaborative AI, the solution autonomously ingests and verifies complex medical documentation, including EDI 270/271 transactions, medical necessity documents, and historical member data.
It also assesses confidence scores and autonomously generates recommendations (approve, reject, manual review) accompanied by detailed reasoning.
The solution transforms labor-intensive workflows through automation reducing processing time, minimizes human error and addresses evolving regulatory requirements such as the upcoming CMS Prior Authorization interoperability mandates (of Jan’2026-27).
In contrast to conventional Prior Authorization workflows that rely on manual processes, our AI-powered solution streamlines and automates key activities, including:
• Completeness check of prior authorization documents
• Entity Extraction from submitted documents
• Validation of 5 major stages comprising 25+ sub-stages
• Verification against Insurers Internal / Backend systems to provide actionable response
• Confidence Score Generation for each verification phase
• Insight generated from historic approved prior authorizations
• Data Driven Decision – Approval / Reject / Manual Review Recommendation
• Comprehensive Summarization
• Intelligent Conversational Bot (ICB) for each prior authorization
• Sharing ‘reviewers mindset’ by analysing past adjudications for similar cases
** Key Benefits**
• Productivity Improvement by >75%
• Turn Around Time Improvement by > 70% (data exchange and workflow between payers and providers, high turnaround time)
• Regulatory Compliance of CMS Prior Authorization interoperability requirements
• Agentic AI based Decision (approve / reject /manual review recommendations) with explanation.
• Better Customer Satisfaction score
Our Gen AI solution is implemented using following AWS Services:
• Amazon Textract
• Amazon Bedrock Agentic AI
• Amazon API Gateway
• Amazon Simple Queue Service (SQS)
• AWS Lambda
• Amazon ECS Clusters and AWS Fargate (for UI)
• AWS S3 and AWS DynamoDB
Highlights
- AI-driven Prior Authorization solution leverages multi-agent architecture to automate 30+ complex validations across eligibility, provider, service, fraud, and document checks. Orchestrator Agent coordinates specialized agents, performing granular validations with confidence scoring. Enables intelligent auto-decision making - approve, deny, or route for manual review based on comprehensive validation results.
- Addresses upcoming CMS Prior Authorization interoperability requirements by Jan'2026-27 through advanced AI solution. Enables Provider Access API and Payer-to-Payer API for seamless care coordination. Automatically handles regulatory compliance, supports data exchange standards, and ensures error-free processing of prior authorization requests while meeting evolving healthcare regulatory mandates.
- GenAI-powered Smart PA solution transforms prior authorization workflow, delivering >75% productivity improvement and >70% faster turnaround time. Utilizing multi-agent AI architecture, the solution automates document verification, entity extraction, and decision-making across 25+ sub-stages. Enables faster, error-free processing with intelligent insights, reducing manual intervention and accelerating insurance authorization workflows.
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