Canada
Puerto Rico
USA
Belgium
France
UK
India
Client Background
A Fortune 10 Digital Health company involved in distributing pharmaceuticals and medical supplies and equipment
Client Need
When providers submit Prior Authorization (PA) requests via EHR systems, the clinical data is often incomplete or inconsistent. Different PA question sets and criteria keep the process highly manual, forcing teams to interpret patient history, pull out supporting evidence, and fill in long forms.
Reduce delays and manual effort in the PA process
Address incomplete and inconsistent clinical data received with PA requests
Simplify interpretation of patient history and evidence extraction
Minimize manual completion of lengthy, varying PA question sets and criteria
Minimize administrative burden and back-and-forth communication with providers
Solution
Deployed an AI-driven PA automation solution that interprets a patient’s clinical story
Automatically completed required PA questions based on available clinical data
Reviewed diagnoses, labs, medications, prior treatments, and clinical notes to extract evidence
Generated evidence-supported responses aligned to branching logic and payer criteria
Reduced back-and-forth communication and administrative burden for clinical teams
Integrated in real time with PA request systems (via Kafka) to streamline clarifications and speed submission
Designed a scalable architecture that extends across drug categories, payers, and patient cohorts
Realized Benefits
50–70% reduction in manual effort for clinical data review and PA form completion
>90% accuracy in matching required criteria and branching decision logic
Decrease in administrative burden for client teams and clinicians
Standardization of evidence-extraction to ensure regulatory auditability
Tools & Technologies
By automating clinical evidence extraction and PA form completion, the client achieved faster and more accurate Prior Authorization processing, significantly reducing manual effort and administrative burden.
Azure OpenAI (GPT-4.1)
Python (FastAPI)
Semantic Kernel (Agentic Orchestration)
Kafka (integration for PA requests)
Aidbox (FHIR Server for patient data)
MongoDB
Docker / Docker Compose
GitHub
SonarQube
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