AuthorizAI - Prior Authorization Multi-Agent System
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation.
Problem Statement
The challenge addressed
Solution Architecture
AI orchestration approach
Illustrative preview (sample data, not verified outcomes): Demo Scenario Selection - Choose from pre-configured authorization scenarios including routine approvals, complex clinical reviews, and denial risk cases
Illustrative preview (sample data, not verified outcomes): Multi-Agent Orchestration - Real-time visualization of parallel agent execution flow with live system metrics and agent status tracking
Illustrative preview (sample data, not verified outcomes): AI Decision Output - Comprehensive authorization decision with medical necessity scoring, criteria evaluation, evidence strength, and technical metadata
Illustrative preview (sample data, not verified outcomes): PA Command Center - Real-time operations dashboard with performance metrics, agent health monitoring, decision feed, and human review queue management
AI Agents
Specialized autonomous agents working in coordination
Orchestrator Agent
Prior authorization involves multiple specialized analyses that must be coordinated efficiently. Without orchestration, processing is sequential and slow. Agent failures can halt the entire workflow without graceful degradation.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Coordinates the multi-agent workflow using hybrid parallel-sequential execution. Initializes the orchestration pipeline, establishes inter-agent communication channels, and manages execution across 5 batches. Monitors agent health and progress. Collects and routes agent outputs to downstream consumers. Implements error handling and retry logic for fault tolerance.
Data Ingestion Agent
Prior authorization requests require data from multiple sources including member databases, claims history, provider credentialing systems, and clinical documentation. Incomplete data leads to delays and incorrect decisions.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Numerical examples are scenario inputs or illustrative outputs, not validated performance results. Collects and normalizes patient data from multiple healthcare systems. Retrieves member demographics, coverage details, and claims history (last 24 months). Fetches clinical documentation including lab results, imaging history, and previous treatments. Assembles comprehensive data packages (847+ data points) with 96% quality scores. Validates data completeness before downstream processing.
Eligibility Verification Agent
Processing authorizations for ineligible members or non-covered services wastes resources. Provider network status affects payment rates. Benefit accumulator status determines member cost-sharing responsibility.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Verifies member eligibility via real-time X12 270/271 EDI transactions. Confirms active coverage, plan benefits, and service-specific authorization requirements. Validates provider network status (in-network, out-of-network, tier designation). Checks benefit accumulators including deductible and out-of-pocket maximum status. Calculates estimated member cost-sharing. Performance requires validation on representative workloads.
Clinical Analysis Agent
Determining medical necessity requires evaluation against complex clinical criteria from InterQual, MCG, and plan-specific guidelines. Manual clinical review is slow and inconsistent. Clinicians may miss relevant criteria or apply them incorrectly.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Evaluates medical necessity using InterQual and MCG clinical criteria. Analyzes diagnosis codes, symptom duration and severity, conservative treatment history, and red flag symptoms. Calculates medical necessity scores (threshold: 70/100). Generates clinical recommendations with evidence strength ratings (strong, moderate, weak). Identifies criteria met and not met with supporting evidence citations. Performance requires validation on representative workloads.
Policy Matching Agent
Health plans maintain hundreds of medical policies with complex approval criteria. Finding applicable policies and evaluating criteria manually is time-consuming. Policy updates may not be consistently applied across reviewers.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Searches medical policy database using semantic matching to find applicable policies for the requested service. Extracts approval criteria from policy documents. Evaluates each criterion against request documentation. Checks policy effective dates and place of service requirements. Identifies alternative service options when primary request doesn't meet criteria. Performance requires validation on representative workloads.
Risk Assessment Agent
Understanding patient risk profile helps prioritize complex cases and predict outcomes. Fraud patterns should be detected before authorization. Without risk stratification, all requests receive equal treatment regardless of complexity.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Calculates CMS-HCC risk scores using model v28 for cost prediction. Maps diagnosis codes to HCC categories with hierarchical condition rules. Computes 30-day readmission probability and complexity assessment. Runs fraud pattern detection algorithms to identify suspicious indicators. Provides risk tier classification (low, moderate, high) to inform processing pathway. Performance requires validation on representative workloads.
Decision Synthesis Agent
Multiple analysis agents may produce conflicting recommendations. Without synthesis, decisions lack coherent rationale. Decision thresholds must be calibrated to achieve target auto-approval rates while maintaining accuracy.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Collects outputs from all analysis agents (Eligibility, Clinical, Policy, Risk). Weights confidence scores based on relevance and historical accuracy. Resolves conflicting recommendations using rule-based logic. Applies decision thresholds to determine approval tier. Generates unified recommendations with weighted confidence scores. Produces comprehensive decision rationale citing all contributing agent findings. Performance requires validation on representative workloads.
Compliance Audit Agent
Prior authorization decisions must comply with HIPAA, state regulations, and CMS guidelines. Audit trails must be complete and immutable. Turnaround time requirements vary by urgency level and state.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Reviews configured data-access, audit-log, turnaround-time and documentation requirements. Records findings with timestamps and actor attribution for authorized reviewers. Outputs are review records, not compliance certificates or regulatory approval.
Worker Overview
Technical specifications, architecture, and interface preview
System Overview
Technical documentation
Tech Stack
10 technologies
Architecture Diagram
System flow visualization