Determines auth requirements, assembles requests against payer rules, tracks status, and drafts appeals — running entirely inside your infrastructure.
The Prior Authorization Agent is an autonomous AI agent that determines when an order needs prior authorization, assembles the request with the right clinical evidence, submits it, and tracks it to a decision.
It reasons over the order, the chart, and current payer rules, and escalates only the cases that need a human, instead of staff working a fax queue.
This is not a rules-lookup chatbot. It is an active agent that checks, submits, follows up, and appeals — deployed air-gapped or on-premise so PHI never leaves your environment.
An auth chatbot tells you whether a code usually needs prior auth. The Prior Authorization Agent checks the specific payer's rules, assembles the request with evidence, submits it, tracks status, and drafts appeals — autonomously.
The Prior Authorization Agent is a true AI agent that goes beyond simple Q&A. It reasons, plans, and executes multi-step workflows autonomously while you retain full code ownership and infrastructure control.
Reads each order and checks whether the specific payer and plan require prior authorization for that service.
When a flagged order is placed, the agent confirms the requirement against the patient's plan and starts the request without waiting for staff.
Pulls the clinical documentation a payer requires — notes, labs, prior treatments — and assembles a complete request package.
Gathers the supporting evidence from the chart and attaches it to the request, matched to the payer's medical-necessity criteria.
Submits requests through payer portals or clearinghouses and tracks each to approval, denial, or pended status.
Submits, polls for status, and updates the EHR and scheduling so staff and patients know where each auth stands.
When a request is denied, drafts an appeal citing the payer's own criteria and the supporting documentation.
Generates a ready-to-review appeal within the appeal window, flagging the specific denial reason it addresses.
Keeps current with changing payer authorization policies and code lists.
Updates its logic when a payer changes auth requirements and re-checks pending orders affected by the change.
The agent monitors new orders and referrals, pulling the patient's plan and the relevant clinical context from the EHR.
It checks payer- and plan-specific rules to decide whether authorization is required and what evidence the payer needs.
The agent assembles the request with supporting documentation, submits it through the payer channel, and updates the EHR and schedule.
It tracks the request to a decision, drafts an appeal on denial, and learns from denial reasons to strengthen future requests.
The agent maintains an audit trail and reports approval rates, turnaround times, and payer-specific denial patterns.
Reduced auth turnaround time and procedure delays while keeping PHI on-premise.
Raised first-submission approval rates and cut peer-to-peer escalations.
Reduced same-day cancellations from missing authorizations.
Scaled auth volume per FTE and reduced auth-related denials.
Eliminated lapses in authorized care and the associated write-offs.
Reads orders and clinical evidence from Epic and writes authorization status back to the chart and schedule.
Pulls orders and documentation from Oracle Health and updates auth status in the workflow.
Submits and tracks authorization requests through Availity and payer portals, polling for decisions.
Initiates and tracks authorizations within athenahealth's ambulatory workflow.
Routes electronic auth transactions and ingests responses to update status automatically.
Holds or releases scheduling based on authorization status to prevent unauthorized-care cancellations.
You receive the complete codebase and operate the authorization workflow permanently, with no black-box SaaS dependency.
Deploy entirely within your own infrastructure so PHI never leaves your perimeter.
Run on AWS, Azure, Google Cloud, or your own data centers. ibl.ai is a certified partner of all three hyperscalers.
Choose and swap the underlying model without rebuilding your authorization workflows.
No patient data is sent to ibl.ai. Every check, submission, and decision is logged to your own immutable audit trail.
Proactive, automated submission cuts the time from order to authorization by more than half.
Evidence-rich, criteria-matched requests raise first-pass approval rates.
Tracking auths to completion before the visit reduces same-day cancellations from missing authorizations.
Automating checks, submissions, and follow-ups frees auth staff for exceptions and patient communication.
Enterprise-wide flat-fee licensing eliminates per-seat authorization SaaS pricing.
See how ibl.ai deploys autonomous AI agents you own and control — on your infrastructure, integrated with your systems.