AI agent · Healthcare · Review against rules
Prior authorisation
The agent reads the patient record, drafts the request the payer or scheme expects, checks each condition before submission and follows the request to a decision. A clinician signs every request; staff handle refusals and unusual cases.
Typical volumes for this process, not a client figure.
Forms filled from a record that already contains the answers.
Drafted from the record, checked against the scheme rules, submitted and tracked.
Where the time goes today
Many treatments, scans, medicines and stays need the agreement of the payer or scheme before they are provided. Each has its own form and its own conditions: a documented failed first-line treatment, a minimum symptom duration, a specialist's report with specific sections, a ceiling on quantity or length. Administrative staff or clinicians complete the form by copying from the patient record: diagnosis, history, earlier treatments and their dates, results. The record usually holds every answer already. Someone still reads it and retypes it into a portal.
Time goes on finding evidence in long records and on keeping track of each payer's current conditions. Mistakes cost more time than they save. A request sent without the required report comes back or is refused, the treatment date slips and the patient waits. Pending requests are followed up by phone or by checking portals one at a time, and an agreement that expires or needs renewal is often noticed only when the patient arrives for treatment.
How the agent works
- Identify the requirementFrom the order or referral and the patient's cover, the agent determines whether this act needs prior agreement and which form and conditions apply.
- Find the evidenceIt locates in the record what each condition asks for (diagnosis, earlier treatments with dates, results, relevant notes) and links every answer to its source entry.
- Check each conditionIt tests the draft against the scheme's conditions: a required report missing, a duration above what is covered, a prerequisite treatment not documented. Gaps are listed for the clinician, never filled in.
- Draft for sign-offThe completed request goes to the responsible clinician with gaps highlighted and sources one click away. Nothing is sent without that signature.
- Submit and trackAfter sign-off, the agent submits through the payer's portal or interface, records the reference, checks status, and alerts staff to requests for more information, decisions, and expiry or renewal dates.
What stays with a person
Clinical judgement stays with clinicians: whether the treatment is appropriate, how to describe the clinical picture, whether to ask for an exception when a condition is not met. The agent never writes a clinical justification that is not in the record and never submits without the responsible clinician's signature.
Staff handle refusals and appeals, discussions with the payer's reviewers, urgent requests made by phone, and patients whose cover is unclear. They also decide what to tell the patient and whether to schedule while agreement is still pending.
What it reads, what it produces
| It reads | It produces |
|---|---|
| The patient record: diagnoses, notes, results, medication, earlier treatments | A draft request with every answer linked to its source in the record |
| Orders and referrals | A condition-by-condition checklist showing what is met and what is missing |
| The patient's cover and eligibility details | A submission record: reference, date, signatory, version of the conditions used |
| Each payer's or scheme's conditions and forms, with the date each version took effect | Status alerts and a worklist of requests that need staff |
| Payer portals or interfaces, for request status | |
| The scheduling system, for planned treatment dates |
Controls that come with it
- No submission without clinician sign-off; the agent cannot sign.
- Each payer's conditions are versioned and owned by a named person, and changes are tested on past requests before use.
- Every answer on the form cites its source; the agent adds no clinical content that is not in the record.
- Access is limited to records with a pending order, and every read is logged under the health data rules that apply to you.
- A submitted request can be withdrawn or corrected through the payer's own procedure, and the agent flags when a correction is needed.
How you know it works
- Requests returned for missing information, before and after go-live
- Time from order to submission, and from submission to decision
- Treatments rescheduled because agreement was not in place
- Clinician time per request
- Agreements that expired without renewal
Is your process ready?
- Each payer's conditions are written in documents you can obtain, and someone keeps them current.
- The record system can be read by software through an interface, payer portals accept submissions by software or offer an interface, and the terms of both permit it.
- A clinician can check a draft in minutes, because every answer points to its source.
- Enough requests go to a few payers that drafting takes clinical and administrative time every week.
- Departments complete the same kind of request the same way. If each clinic has its own workaround, agree one method first.
The five candidacy checks are explained, with an exam, in the free Module 01.
What goes wrong
- Payer conditions change with little notice, and stale conditions produce confident drafts that are then refused.
- Evidence sits in scanned letters from other providers that read poorly, so drafts show gaps that are not real.
- Once drafts look reliable, clinicians sign without reading. Sample signed requests and review them.
- Portals that block automated access or change their layout break submission. Prefer an interface where the payer offers one.
Questions we get
Does the agent decide whether a treatment is needed?
No. The clinician decides what the patient needs. The agent checks whether the request, as the record supports it, meets the payer's written conditions, and drafts the form. If a condition is not met, it says so; the clinician then decides whether to document further, request an exception or choose another route. The payer makes the final decision.
What if the record lacks the evidence the payer asks for?
The agent lists the gap against the condition that requires it, for example a report missing a required section. It does not fill the gap or paraphrase something close. The clinician decides whether the evidence exists elsewhere, needs to be produced, or whether to proceed without it and explain why in their own words.
How is patient data protected?
The agent runs in your own account, so records stay where your rules require. It reads only the records of patients with a pending order, every access is logged, and the access model is approved by whoever is responsible for data protection in your organisation before go-live. The health data rules that apply to you govern retention and disclosure.
How do you know the drafts are right before go-live?
The agent runs on past requests whose outcomes are known: approved, refused or returned for information. You compare its drafts and flagged gaps with what was sent and what the payer decided, and read every difference. The same set is rerun whenever a payer changes its conditions or the underlying model changes.
Want this agent on your process?
Tell us about your version of this process — volumes, systems, what goes wrong. A person answers with an approach and a price, usually within two working days, or tells you it is the wrong project.