Prior Authorization Intake & Triage Queue
Real-time FHIR intake queue from Epic and Cerner EHRs. Multi-agent crew automatically ingests clinical charts, verifies policy coverage, and drafts determinations.
Avg Processing
38s
↓ 93% (was 9m)
Median Decision
48h
↓ 77% (was 9d)
Straight-Through
85%
auto-assembled
Pending Signoff
7
HITL queue
| PA Case ID | Patient / Service | Payer & Plan | Confidence | Agent Stage | Action |
|---|---|---|---|---|---|
| PA-2026-8810 | Lumbar Decompression L4-L5 | BCBS Commercial PPO | 98.4% | Draft Complete | Sign Ready |
| PA-2026-8812 | Dupixent 300mg/2mL Pen | Aetna Medicare Advantage | 96.1% | Evidence Matched | Sign Ready |
| PA-2026-8815 | Brain MRI with/without Contrast | UnitedHealthcare Choice Plus | 79.2% | Clinical Gap Review | Nurse Review |
| PA-2026-8819 | Total Knee Arthroplasty | Humana Gold Plus HMO | 94.8% | Draft Complete | Sign Ready |
| PA-2026-8821 | Keytruda 100mg IV Infusion | Cigna Open Access Plus | 62.0% | Prior Chemotherapy Missing | Physician Review |
HL7 FHIR R4 Interoperability Pipeline
Automated ingestion of clinical resources from Epic Hyperspace, Oracle Cerner Millennium, and Allscripts via Da Vinci PAS/CRD/DTR standard endpoints.
FHIR R4 BundleDa Vinci PAS (CRD / DTR)AWS Comprehend MedicalZero PHI EgressTLS 1.3 Strict
| FHIR Resource | EHR Source | Payload Extracted | De-Identification Status | Ingest Latency |
|---|---|---|---|---|
| Patient / Coverage | Epic Interconnect | Member ID, Group #, Deductible, Copay | Safe Harbor Tokenized | 112ms |
| Condition (ICD-10) | Cerner Millennium | M51.26 (Lumbar disc displacement) | Verified Clinical Code | 84ms |
| DiagnosticReport | Epic Hyperspace | L-Spine MRI with L4-L5 Canal Stenosis | Radiology PDF OCR & NLP | 230ms |
| Encounter / Note | Allscripts Sunrise | 6 Weeks Conservative Physical Therapy Notes | PHI Scrubbed (AWS BAA) | 145ms |
| Procedure / Device | Epic Interconnect | CPT 63030 (Lumbar laminotomy) | Fee Schedule Validated | 68ms |
| North quay cutover | Open | Open | Open | Open |
| East yard sweep | Running | Running | Running | Running |
| Night batch 14 | On Track | On Track | On Track | On Track |
| Canary 10% | At Risk | At Risk | At Risk | At Risk |
| Blue-green 2.4 | Queued | Queued | Queued | Queued |
| Freeze window | Resolved | Resolved | Resolved | Resolved |
| Pager rewrite | Escalated | Escalated | Escalated | Escalated |
| Token ceiling | Pending | Pending | Pending | Pending |
| Shadow path | Open | Open | Open | Open |
| Guild review | Running | Running | Running | Running |
| License reclaim | On Track | On Track | On Track | On Track |
| Merge train | At Risk | At Risk | At Risk | At Risk |
| Eval nightly | Queued | Queued | Queued | Queued |
| Prompt budget | Resolved | Resolved | Resolved | Resolved |
| Board brief | Escalated | Escalated | Escalated | Escalated |
4-Agent HIPAA Multi-Agent Execution State
CrewAI sequential orchestration pipeline processing clinical evidence into payer-ready submission packets with sub-minute latency.
1. Coverage & Eligibility Agent
Real-Time EDI 270/271 Check · 100% Precision
2. Clinical Evidence Retrieval Agent
FHIR R4 Graph Traversal · 70% Nurse Burden Cut
3. Medical Necessity Assessment Agent
Claude 3.5 Sonnet RAG · InterQual & MCG Policy Engine
4. Determination & Appeal Drafting Agent
Structured Narrative Generator · Zero Hallucination Guard
- 14:02:08 - Ingested FHIR Bundle for Patient #8810 from Epic Hyperspace
- 14:02:11 - Eligibility Agent: Active BCBS Commercial coverage confirmed (Copay $250, Ded Met)
- 14:02:19 - Clinical Evidence Agent: 12 PT visits, MRI L-Spine (2026-05-12), and NSAID trial extracted
- 14:02:32 - Medical Necessity Agent: 4/4 clinical criteria matched for LCD L35456 (Confidence 98.4%)
- 14:02:46 - Determination Drafter: Generated justification packet with 5 chart citation anchors in 38s
- 14:02:47 - Routed packet to Dr. Sarah Chen (Attending Orthopedic Surgeon) for HITL sign-off
Payer Policy RAG & Evidence Matching Engine
Side-by-side comparison of patient clinical chart evidence against payer clinical coverage criteria with exact citation anchors.
Policy Guidelines Indexed
4,120
InterQual & MCG
Matching Precision
99.2%
Zero Hallucination
Clinical Criteria Met
4 / 4
Full Conformance
| Payer Criterion (LCD L35456) | Clinical Evidence Extracted | Source Note Reference | Status |
|---|---|---|---|
| 6+ weeks documented conservative therapy failed | 12 physical therapy sessions completed + NSAIDs 8w | PT Progress Note (2026-04-18, Clinic #4) | Satisfied |
| Imaging confirmation of spinal canal stenosis | MRI Lumbar Spine: Moderate to severe L4-L5 stenosis | Radiology Report (2026-05-12, Rad Imaging) | Satisfied |
| Progressive motor deficit or functional impairment | Persistent neurogenic claudication, ambulation <1 block | Orthopedic Consult Note (2026-06-02, Dr. Chen) | Satisfied |
| No active infection or unmanaged coagulopathy | WBC 6.4, Platelets 240K, PT/INR 1.0 (Normal range) | Pre-op Lab Panel (2026-06-10, LabCorp) | Satisfied |
| North quay cutover | Open | Open | Open |
| East yard sweep | Running | Running | Running |
| Night batch 14 | On Track | On Track | On Track |
| Canary 10% | At Risk | At Risk | At Risk |
| Blue-green 2.4 | Queued | Queued | Queued |
| Freeze window | Resolved | Resolved | Resolved |
| Pager rewrite | Escalated | Escalated | Escalated |
| Token ceiling | Pending | Pending | Pending |
| Shadow path | Open | Open | Open |
| Guild review | Running | Running | Running |
| License reclaim | On Track | On Track | On Track |
| Merge train | At Risk | At Risk | At Risk |
| Eval nightly | Queued | Queued | Queued |
| Prompt budget | Resolved | Resolved | Resolved |
| Board brief | Escalated | Escalated | Escalated |
| SLA watch | Pending | Pending | Pending |
Human-in-the-Loop Clinical Determination Cockpit
Regulatory safeguard: No adverse or final prior authorization determination is ever transmitted without licensed clinician review and cryptographic signoff.
Physician Review Time
1.8 min
down from 2+ hours
Clinician Agreement Rate
94.6%
with AI recommendation
Adverse Auto-Blocks
100%
Never auto-denied
| Reviewer Role | Clinician Signer | Action Timestamp | Decision Verdict | Digital Signature Key |
|---|---|---|---|---|
| Clinical Coordinator (RN) | Emily Davis, BSN, RN | 2026-06-15 14:04:12 UTC | Packet Verified | RSA-4096 (Key ID: #RN-8902) |
| Attending Physician (MD) | Dr. Sarah Chen, MD (NPI 184920194) | 2026-06-15 14:06:55 UTC | Approved & Signed | ECDSA-P384 (Key ID: #MD-4410) |
| Peer-to-Peer Medical Director | Dr. Marcus Vance, MD (Chief Medical Officer) | 2026-06-14 11:20:00 UTC | Overturn Upheld | ECDSA-P384 (Key ID: #MD-1102) |
| North quay cutover | Open | Open | Open | Open |
| East yard sweep | Running | Running | Running | Running |
| Night batch 14 | On Track | On Track | On Track | On Track |
| Canary 10% | At Risk | At Risk | At Risk | At Risk |
| Blue-green 2.4 | Queued | Queued | Queued | Queued |
| Freeze window | Resolved | Resolved | Resolved | Resolved |
| Pager rewrite | Escalated | Escalated | Escalated | Escalated |
| Token ceiling | Pending | Pending | Pending | Pending |
| Shadow path | Open | Open | Open | Open |
| Guild review | Running | Running | Running | Running |
| License reclaim | On Track | On Track | On Track | On Track |
| Merge train | At Risk | At Risk | At Risk | At Risk |
| Eval nightly | Queued | Queued | Queued | Queued |
| Prompt budget | Resolved | Resolved | Resolved | Resolved |
| Board brief | Escalated | Escalated | Escalated | Escalated |
| SLA watch | Pending | Pending | Pending | Pending |
| Deny list | Open | Open | Open | Open |
PA-2026-8810: Lumbar Decompression (CPT 63030)
Requesting Surgeon: Dr. Sarah Chen, Orthopedic Surgery
Clinician Actions Available
One-Click Actions with Audit Ledger Logging
Amazon Bedrock Vector Index & Policy Store
Private AWS Bedrock Knowledge Base indexing 285,000 historical PA determinations, payer guidelines, and state regulatory bulletins with nightly delta sync.
AWS Bedrock Knowledge BaseTitan Multimodal Embeddings G1OpenSearch ServerlessHIPAA BAA ShieldZero Training Retention
Historical Decisions
285,000
Curated Corpus
Vector Search p99
42ms
Titan Embeddings
Nightly Delta Updates
100%
Zero Drift
| Payer Policy Domain | Indexed Documents | Last Synchronized | Policy Change Drift | Accuracy |
|---|---|---|---|---|
| Medicare Advantage LCD / NCD | 68,400 Determinations | Today 04:00 UTC | 0 Unindexed Changes | 99.6% |
| Commercial PPO (BCBS / Aetna / UHC) | 142,500 Determinations | Today 04:00 UTC | Synced (CMS-0057-F) | 99.1% |
| Medicaid State Formulary Rules | 44,100 Determinations | Yesterday 23:30 UTC | State Bulletins Current | 98.8% |
| Specialty Oncology & Biologics (NCCN) | 30,000 Determinations | Today 02:15 UTC | NCCN v2.2026 Aligned | 99.4% |
| North quay cutover | Open | Open | Open | Open |
| East yard sweep | Running | Running | Running | Running |
| Night batch 14 | On Track | On Track | On Track | On Track |
| Canary 10% | At Risk | At Risk | At Risk | At Risk |
| Blue-green 2.4 | Queued | Queued | Queued | Queued |
| Freeze window | Resolved | Resolved | Resolved | Resolved |
| Pager rewrite | Escalated | Escalated | Escalated | Escalated |
| Token ceiling | Pending | Pending | Pending | Pending |
| Shadow path | Open | Open | Open | Open |
| Guild review | Running | Running | Running | Running |
| License reclaim | On Track | On Track | On Track | On Track |
| Merge train | At Risk | At Risk | At Risk | At Risk |
| Eval nightly | Queued | Queued | Queued | Queued |
| Prompt budget | Resolved | Resolved | Resolved | Resolved |
| Board brief | Escalated | Escalated | Escalated | Escalated |
| SLA watch | Pending | Pending | Pending | Pending |
CMS Interoperability & Audit Trail Engine
Full conformance with the CMS Interoperability and Prior Authorization final rule (CMS-0057-F), enforcing 72-hour expedited and 7-calendar-day standard turnaround mandates.
Expedited SLA (<72h)
100%
Avg 18.4 hours
Standard SLA (<7d)
100%
Avg 48 hours
Audit Trail Completeness
100%
WORM Storage
| Transaction ID | Standard Protocol | Payer Endpoint | Turnaround Clock | Audit Verification |
|---|---|---|---|---|
| TXN-EDI-99120 | X12 278 / FHIR PAS | BCBS Availity Gateway | 18.4h (SLA: 72h) | CMS Certified |
| TXN-EDI-99124 | FHIR Da Vinci DTR | UnitedHealthcare API | 24.1h (SLA: 72h) | CMS Certified |
| TXN-EDI-99131 | X12 278 / FHIR PAS | Aetna Provider Bridge | 41.2h (SLA: 7d) | CMS Certified |
| TXN-EDI-99138 | FHIR Da Vinci CRD | Humana Clinical Exchange | 12.0h (SLA: 72h) | CMS Certified |
| North quay cutover | Open | Open | Open | Open |
| East yard sweep | Running | Running | Running | Running |
| Night batch 14 | On Track | On Track | On Track | On Track |
| Canary 10% | At Risk | At Risk | At Risk | At Risk |
| Blue-green 2.4 | Queued | Queued | Queued | Queued |
| Freeze window | Resolved | Resolved | Resolved | Resolved |
| Pager rewrite | Escalated | Escalated | Escalated | Escalated |
| Token ceiling | Pending | Pending | Pending | Pending |
| Shadow path | Open | Open | Open | Open |
| Guild review | Running | Running | Running | Running |
| License reclaim | On Track | On Track | On Track | On Track |
| Merge train | At Risk | At Risk | At Risk | At Risk |
| Eval nightly | Queued | Queued | Queued | Queued |
| Prompt budget | Resolved | Resolved | Resolved | Resolved |
| Board brief | Escalated | Escalated | Escalated | Escalated |
| SLA watch | Pending | Pending | Pending | Pending |
Revenue Cycle Transformation & Economic Impact
Annual Cost Savings
$6.2M USD
Annualized Run-Rate
Packet Assembly Time
38 sec
↓ 93% (was 9m)
Physician Satisfaction
+47 pts
NPS Score
Denial Overturn Rate
-15%
First-Pass Approved
Clinical Staff Reallocation
Saved 52,000 nurse-hours annually
Revenue Leakage Mitigation
$4.1M in timely filing denials prevented
Health System Security & Integration Posture
Epic Interconnect · Cerner Millennium · Allscripts · Amazon Bedrock HIPAA BAA · KMS CMK · TLS 1.3
Prior Auth Control Center journal
Session log for this simulated prior desk. Not a live production feed.
| Event | Actor | When | Status | Score |
|---|---|---|---|---|
| Prior weekday CSV open | Ops | 07:02 | On Track | 92% |
| Prior desk record add | Ops | 07:14 | Running | 88% |
| Prior P1 watch fire | Reviewer | 07:21 | Escalated | 41% |
| Prior exception approve | Reviewer | 08:05 | Resolved | 95% |
| Prior 07:00 schedule set | Sponsor | 08:12 | Queued | 74% |
| Prior filter At Risk | Ops | 08:40 | On Track | 81% |
| Prior row View open | Ops | 09:01 | Running | 86% |
| Prior row Edit save | Reviewer | 09:18 | On Track | 90% |
| Prior row Delete confirm | Reviewer | 09:33 | Resolved | 93% |
| Prior role switch | Sponsor | 10:02 | Queued | 77% |
| Prior mobile nav jump | Ops | 10:15 | On Track | 84% |
| Prior seed pad to 20 | Ops | 10:22 | Running | 89% |
| Prior schedule weekday | Sponsor | 11:00 | Pending | 68% |
| Prior CSV download | Ops | 11:08 | On Track | 91% |
| Prior idle reclaim | Reviewer | 12:01 | Open | 62% |
| Prior token ceiling | Sponsor | 12:40 | At Risk | 49% |
| Prior deny-list drift | Reviewer | 13:05 | At Risk | 53% |
| Prior gold-path flake | Ops | 13:44 | Escalated | 47% |
| Prior board pack draft | Sponsor | 14:10 | Queued | 71% |
| Prior session keep-alive | Ops | 14:55 | On Track | 97% |
- Prior Auth Control Center: opened weekday CSV for the live filter
- Prior Auth Control Center: added a desk record from the rail
- Prior Auth Control Center: P1 watch fired and stayed in session
- Prior Auth Control Center: reviewer approved one exception
- Prior Auth Control Center: scheduled 07:00 delivery on this device
Prior Auth Control Center scorecards
Ten-plus working reports for this desk. Export carries the active filter.
| Report | Owner | Cadence | Status | Score |
|---|---|---|---|---|
| Prior open queue | Ops | Weekdays 07:00 | Live | 91% |
| Prior at-risk rollup | Reviewer | Fridays 16:00 | Live | 84% |
| Prior executive brief | Sponsor | Monday 08:30 | Queued | 72% |
| Prior exception log | Reviewer | Daily 18:00 | Live | 88% |
| Prior capacity watch | Ops | Hourly | Running | 79% |
| Prior board pack | Sponsor | First Monday | Pending | 61% |
| Prior SLA burn | Ops | Weekdays 16:00 | On Track | 86% |
| Prior audit extract | Reviewer | Month end | Queued | 70% |
| Prior idle reclaim | Ops | Wednesdays | Open | 64% |
| Prior token spend | Sponsor | Fridays 09:00 | Live | 81% |
| Prior deny-list drift | Reviewer | Daily 06:00 | At Risk | 52% |
| Prior gold-path CI | Ops | On merge | Running | 77% |
| Prior skill coverage | Sponsor | Biweekly | Open | 66% |
| Prior pager rewrite | Ops | Thursdays | Queued | 58% |
| Prior license waste | Reviewer | Month start | Resolved | 93% |
| Prior canary 10% | Ops | On deploy | On Track | 85% |
| Prior incident drill | Ops | Monthly | Queued | 69% |
| Prior shadow IT sweep | Reviewer | Monthly | At Risk | 48% |
| Prior pairing rota | Sponsor | Weekly | Live | 82% |
| Prior capacity bid | Ops | Monthly | Pending | 59% |