Prior authorization packets, assembled before your coordinator opens the portal
The AMA's 2025 survey puts prior authorization at an average of 40 requests and 13 hours of physician and staff time a week for each physician. Much of that time goes into the lookup before a request and the status chasing after it. The agent does that first pass. Your coordinator keeps the judgment calls and the submit click.
Examples use invented names and figures.
What the agent does
- Step 1Reads the order
From the EHR order, a referral or a message from the provider. It finds the CPT or HCPCS code, the diagnosis and the patient's plan, then checks the payer's published list to see whether authorization is needed.
- Step 2Builds the packet
It pulls the notes, imaging, prior treatment and results the payer's criteria ask for and cites the chart page for each one. If the chart lacks something the criteria need, it says so and stops there.
- Step 3Drafts the submission
Portal fields or the payer's fax form are filled from the chart and the order. The packet then waits in a queue for your coordinator to review and submit.
- Step 4Tracks the clock
It records the deadline that applies to each request and drafts replies to requests for more information. Under CMS-0057-F, impacted payers generally must decide expedited non-drug requests within 72 hours and standard ones within 7 calendar days, and exchange plans are excluded from those timeframes.
Medical necessity stays with your clinicians. The agent drafts from cited chart evidence, and staff check for unsupported statements before submission. Peer-to-peer calls and the decision to treat before an approval stay with your team. At launch, staff approve every submission and filing. Any later automation needs an agreed scope and documented validation.
- Requests per week and staff minutes per request, before and after
- First-pass approval rate
- Requests for more information per 100 submissions
- Days from order to decision
- Denials by the reason the payer gave
Questions about this agent
Does it work with our EHR?
The packet is built from documents and data your EHR already holds, whether that is athenaOne, eClinicalWorks, NextGen, ModMed or Epic. The sprint works on sample documents with made-up patient details, so it needs no access. For a build, we confirm how your system shares documents before we quote.
Can it submit through Availity or the payer portal?
It drafts the fields for whichever channel the payer uses, including Availity, the payer's own portal or a fax form. Whether it may enter them directly depends on the portal's terms. At launch, a coordinator approves every submission.
What happens when the chart does not support the request?
The agent lists what the payer's criteria ask for and what it could not find, with the pages it checked. It does not write around the gap. The coordinator and the ordering clinician decide what happens next.