Imaging & radiology
High-volume MRI/CT authorizations matched to payer policies before scheduling.
Revenue Cycle · AI Agent
Prior Authorization Automation Agent
The agent reads the order and payer rules, drafts the authorization packet, and submits it electronically — turning a multi-day fax-and-phone chase into a same-day request with a human sign-off.
Human-in-the-loopHIPAA-ReadyAudit LoggedFHIR PAS
Trusted by global innovators
Why prior auth is the slowest step in the revenue cycle
Manual prior auth — reading the order, hunting the payer's medical policy, re-keying it into a portal or fax — is the revenue cycle's slowest step, and every re-key risks the wrong CPT, a missing document, or a denial. The agent pulls the order and clinical data from the EHR over FHIR, matches payer rules, assembles the packet, and submits over X12 278 or FHIR PAS — a coordinator approving every request.
The prior-auth pipeline, end to end
From EHR order to submitted 278 to tracked response, with a review gate before every submission.
Key Capabilities
Automation grounded in the CMS Interoperability rule and Da Vinci guides.
Payer-rule matching
Maps the order's ICD-10 and CPT/HCPCS codes to the payer's medical-necessity policy.
Packet assembly with citations
Drafts the request with chart evidence for each policy criterion, cited for review.
X12 278 & FHIR PAS submission
Submits over X12 278 or the Da Vinci PAS FHIR API — the rails the CMS 2027 API mandate standardizes on.
Coordinator sign-off gate
Every request stops for coordinator review before it reaches the payer.
Response tracking & pend handling
Reads the 278 response, writes auth numbers back to the EHR, and queues pended requests.
Who runs it
Deployment scenarios
The same agent, tuned to where authorization volume hurts.
Specialty pharmacy & infusion
Drug-specific medical-necessity packets with required labs and step-therapy history.
Surgical scheduling
Procedure authorizations submitted early so cases aren't delayed for a missing auth.
Payers & delegated entities
Standing up FHIR PAS intake ahead of the CMS 2027 API mandate.
Expected impact once the agent is live
Directional targets validated against your baseline, never assumed.
Same-day
Submission for clean, rule-matched requests
1 gate
Human sign-off before every payer submission
100%
Requests submitted over 278 / FHIR PAS, no portals
Compliance-First Healthcare App Development Services Backed by Global Standards
15-Minute Scoping Call01
HIPAA
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, strict access controls, and traceable audit logs.
02
GDPR
General Data Protection Regulation
Implement lawful consent flows, data minimization, retention controls, and secure processing for sensitive health data.
03
FHIR
Fast Healthcare Interoperability Resources
Enable standardized health data exchange across apps, care teams, and systems through robust FHIR-ready APIs.
04
HL7
Health Level Seven International
Support enterprise-grade interoperability with HL7-based integrations for records, events, and clinical messaging workflows.
05
HITRUST
Health Information Trust Alliance
Align security programs to healthcare-specific control and risk management practices trusted by providers and ecosystem partners.
06
HITECH
Health Information Technology for Economic and Clinical Health Act
Design with breach notification readiness, digital record safeguards, and operational controls that support regulated care programs.
07
SaMD
FDA Software as a Medical Device
Plan software quality, traceability, and documentation pathways for products that may require SaMD review and submission.
08
MDR (EU)
Medical Device Regulation (European Union)
Prepare EU market-ready processes for risk classification, evidence tracking, and lifecycle governance under MDR expectations.
09
SAMHSA
Substance Abuse and Mental Health Services Administration
Apply confidentiality controls and consent-aware sharing models for behavioral and mental health data experiences.
Standards it speaks
Transactions and controls
X12 278FHIR PASFHIR R4CDS HooksHIPAACMS
How It Works
Capture → decision → submit → write-back
Four stages, bounded by payer rules, with human approval before submission.
1.
Capture the order
Ingests the order, diagnosis, and clinical data from the EHR over FHIR R4 (ServiceRequest, Condition, DocumentReference).
FHIR R4 intake
2.
Match rules & draft
Resolves the payer and plan, matches codes to policy, and drafts the evidence — flagging gaps, not guessing.
Rule-bounded model
3.
Human review & submit
A coordinator approves or edits; the agent then transmits over X12 278 or FHIR PAS, never without a logged action.
Sign-off required
4.
Track & write back
Parses the 278 response, writes the auth number back to the EHR, and routes pended cases to staff with the payer's reason.
EHR write-back
Related proof of compliant AI delivery
Read Case StudyLera Health: compliant women's health platform
Not a prior-auth deployment, but it shows how we ship AI healthcare software: privacy-first data, consented PHI flows, human-reviewed outputs — the discipline behind our revenue-cycle agents.
Compliance & Guardrails
15-Minute Scoping CallGuardrails on every request
A human owns every payer-facing decision, and every action is reconstructable.
PHI handling
Clinical data stays in HIPAA-ready, encrypted infrastructure under a signed BAA, minimum-necessary per request.
Human-in-the-loop
A coordinator approves every packet; the model drafts and matches rules, never transmits on its own.
Explainability
Each packet cites the policy criterion and chart evidence behind it, traceable in audit.
Audit logging
Every ingest, draft, edit, approval, and 278 transmission is timestamped and attributed.
Frequently Asked Questions
Yes. PHI stays in HIPAA-ready, encrypted infrastructure under a signed BAA with least-privilege access, audit-logged for Security Rule accountability.
Ready to automate prior authorization?
Tell us your top authorization types and payers. We'll return an architecture plan with the review gate, X12 278 / FHIR PAS submission path, and a 2027-ready rollout.
contact@agnotic.com
Partnerships
contact@agnotic.com