Health Insurer Prior Auth
A health insurer automated prior authorisation with a policy engine and audit trail — clinical policy guardrails, human review for exceptions, and regulatory-ready documentation.
A health insurer automated prior authorisation with a policy engine and audit trail — clinical policy guardrails, human review for exceptions, and regulatory-ready documentation.
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Challenge
Prior auth backlogs delayed care and created provider friction — manual review against clinical policies was slow and inconsistently documented.
Production deployment — not proof-of-concept
Governed agents with full audit trails
Embedded FDE delivery model
Operational accountability through go-live
Approach
Agent matched requests against clinical policy knowledge base with citation grounding. Auto-approval within policy bounds; clinical reviewers handled exceptions with agent-prepared summaries.
Results
50% of standard prior auth decisions automated. Full audit trail for state regulator review. Average decision time cut from 3 days to 4 hours.
Production outcomes, not pilot metrics.
Standard prior auth automated.
Average decision time (from 3 days).
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