AI prior authorization processing reads each inbound determination letter, identifies the patient, service and payer, and separates approvals from denials. Denials are treated as time-bound: the appeal window is identified, the item is escalated rather than filed, and it is tracked against that deadline until someone closes it.
Nobody files a denial on purpose. It happens because the letter looks like every other piece of payer correspondence.
Same payer letterhead, same format, same envelope. The difference is a line of text in the middle.
The appeal deadline is stated once, often in small print, sometimes only by reference to a policy.
A denial in a stack of routine correspondence gets the same two seconds of attention as the rest.
Whether it is a coding issue, a medical necessity question or a missing document determines who should handle it — and it is not on the first line.
Denials fall between clinical and billing. Without an assigned owner they wait for someone to volunteer.
By the time anybody notices, the window has often closed and the revenue is simply gone.
The goal is not to appeal automatically. It is to make sure a human sees it in time.
Determinations split into approvals and denials on content, so a denial never sits in the same pile as routine correspondence.
Denial reason, service, payer and patient pulled out, so the item routes to whoever handles that category.
The appeal deadline is surfaced explicitly and attached to the item as a tracked date.
Denials are escalated on arrival and tracked against the deadline until closed, with reminders before it expires.
It reads each determination letter, identifies the patient, service and payer, separates approvals from denials, extracts the denial reason, identifies the appeal window and escalates the item against that deadline.
No. It ensures a person sees the denial in time, with the reason extracted and the deadline attached. The appeal decision and submission stay with your team.
From the language of the determination itself where stated. Where a letter references a policy rather than a date, that ambiguity is flagged rather than guessed at.
It escalates to human review. A determination that cannot be classified confidently is exactly the kind of item that should not be automated silently.
Determination letters are read on content rather than on a per-payer template, so format variation between payers is handled without per-payer configuration.
The pipeline determinations arrive through.
Where authorisation problems usually start.
How deadline tracking and escalation work.
Send a month of payer correspondence. We will show you which denials would have been escalated.
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