Autonomous Prior Authorization & Clinical Intake Packet Synthesizer

The Prior Authorization Friction Point#

When a specialist orders an advanced imaging study, biologic therapy, or surgical procedure, commercial payers require documented proof that the patient met specific clinical criteria (such as 6 weeks of failed conservative therapy or specific biomarker thresholds).

Today, patient access coordinators manually read through 50–200 pages of inbound referral faxes and progress notes to copy-paste clinical evidence into payer portals.

Reference Architecture Blueprint#

Instead of asking an LLM to write an unverified appeal letter, we build a policy-driven evidence assembler:

Inbound Referral & Chart Bundle (PDF / Fax / FHIR)
  ├── 1. Layout-Aware OCR & Temporal Chunker (Preserves dates, labs, and provider signatures)
  ├── 2. Payer Policy Schema Loader (Loads structured checklist for target CPT + Payer ID)
  ├── 3. Citation-Grounded Evidence Matcher (Locates exact dates & clinical findings per criterion)
  ├── 4. Gap Detector (Flags missing lab or therapy records before submission)
  └── 5. Packet Generator (Produces annotated PDF packet + pre-filled portal summary)

Expected Operational Impact#

• 80% reduction in chart-hunting time for nursing and patient access staff.
• Fewer avoidable technical denials caused by missing attachment pages or overlooked conservative treatment dates.
• Zero clinical hallucination because every satisfied policy criterion is strictly bound to a verbatim source span and document timestamp.