Purchasing Guides / Prior Authorization Request Preparation

Prior Authorization Request Preparation

A purchasing guide to a workflow, deployed in your environment, that reads an order, the chart documents and the payer policy you select, and prepares a prior authorization request with a criteria checklist for your staff to review and submit.

Yearly running cost

Assuming 4,800 requests a year

By hand
$48K / year
1,600 hours of work
Hosted service
$19.2K – 38.4K+ / year
This workflow
$979 / year
Machine usage only; setup, hosting and review are extra.
Where should it read the documents from?

Prepare a prior authorization request from the order, chart documents and the payer policy your staff selects. Staff and clinicians check the draft before anything is sent.

One request includes up to 40 chart pages.

Your clinician decides whether to request the service. Staff submit every request; nothing is sent to a payer automatically.

What is included

Read the uploaded order, chart documents and selected payer policy, fill the request fields, mark each criterion as documented, missing or unclear with page references, and draft a cover letter.

Start with one specialty, the payer policies you use most and authorised example requests with their outcomes. Service and diagnosis codes come from the order; the workflow does not choose them. The connected option adds read-only chart retrieval; it does not write to the record or submit to payers.

How reliable should the preparation be?

Choose how often criterion statuses must be supported by the cited chart page, how many documentation gaps it must find and how accurate the form fields must be.

How these standards are measured

Test on held-out authorised requests from different patients and payers. Check every criterion status against the cited chart page. A criterion marked as documented without support counts as an error; a missing document that is not listed counts as a miss.

Targets for your selected standard
What is checkedTarget
Criteria marked correctlyCriteria with the status a reviewer assigned and a page that supports it, divided by all criteria in the selected policies.≥95%
Missing documents foundCorrectly listed gaps divided by all gaps reviewers labelled; an item marked documented without support counts as a miss.≥95%
Request fields correctForm fields that match the order and chart, divided by all required fields; blank required fields are errors.≥97%
Valid page referencesStatements whose cited document and page belong to the same patient and contain the stated fact, divided by all statements.≥98%

A criterion marked as documented is a pointer to chart evidence, not a judgement that the service is needed. Your clinician makes that decision and payer rules change, so staff confirm the current policy.

How quickly do you need a draft request?

Choose how quickly a draft should be ready after the documents are accepted. Clinician review and payer decision time are separate.

Timing details

Time from accepting a complete set of documents to a stored draft, including text extraction, criteria comparison, queueing and retries. Confirm document size and hardware with your provider.

The target applies to at least 95% of agreed test runs, with 3 in progress at a time.

How much do you want to spend per request?

Choose the machine budget for reading documents and comparing them with payer criteria. Tighter budgets may use smaller models or fewer checks.

Cost details

Includes model calls, local text extraction, retries and shared hosting allocation. Staff review, EHR and payer portal fees and the calling agent are separate. Resubmitted documents are a new run.

Reference machine cost: $0.25 – 0.35 per request at 400 requests a month. The selected cap is a target to test, not a replacement for this estimate.

Where do you want it to run?

Keep patient documents in your cloud or on your own server. Choose whether approved text may go to a model service covered by your agreements.

Data and access details

Runs in a cloud account your organisation has approved for patient data, with restricted access, audit logs and agreed retention.

Only the minimum chart text goes to an approved model service. Confirm a business associate agreement or equivalent terms before patient data is processed.

Send only the minimum chart text needed to an approved model. Keep audit logs, restricted access and agreed retention. No external model calls keeps reading and inference on your hardware.

How do you want to use it?

Use a review page, your current AI agent or a dedicated agent. You can choose more than one.

Anything else your provider should know?

Optional. Your choices are included automatically.

Common questions

Does it decide whether the patient qualifies?

No. It shows where the chart addresses each payer criterion and what is missing. Your clinician decides whether to request the service and staff submit it.

Can it submit to payer portals?

Not in this guide. Staff submit through your existing portal or service. Automated submission is a separate scope with its own approvals.

What about patient privacy?

It runs in your environment. If an external model is used, send only the minimum text and agree a business associate agreement or equivalent terms first. You can also choose no external model calls.

Payer policies change. How does it keep up?

Staff select or upload the current policy for each request. The workflow does not assume a policy is current; updating your policy library is your team’s task.

Do I need this if I already use an authorization service?

Not necessarily. Keep the service if it covers your payers and documentation needs. Buy this when staff still spend time finding chart evidence before each request.

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