PA Intelligence — Prior Auth for Health Plans

Prior authorization is one of the slowest and costliest processes in health insurance. Plans staff nurses and medical directors to read clinical packets by hand, cross-check them against medical policy, and chase missing documentation — weeks of turnaround per case — while the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) compresses decision timelines and mandates transparent, FHIR-based, auditable determinations.

PA Intelligence for Payers is a managed SaaS adjudication engine on Microsoft Fabric and Azure. It ingests a PA submission as a clinical PDF or FHIR bundle, extracts the clinical evidence with an LLM layer, scores it against the plan’s own medical-policy criteria, and — when documentation is missing — searches connected claims, pharmacy, and encounter data for corroborating evidence before rendering a determination. The final decision is made by a deterministic rules engine, not the model, so every outcome is reproducible and explainable, with an enforced clinician-review path for the edge cases that should never be fully automated.

What you can use it for

Submission intake

Accept clinical PDFs (via OCR) and FHIR bundles, validating member eligibility and the matching medical policy at intake.

Clinical evidence extraction

Pull eight structured fields — chief complaint, treatment history, imaging, functional status, labs, medications, assessment, and contraindications — from the submitted documents.

Policy criteria matching

Score each medical-policy criterion as met, not-met, or not-found against the evidence, with reasoning and confidence on every line.

Cross-system evidence search

When a required criterion isn’t in the packet, query claims, pharmacy, encounter notes, and prior approved PAs to surface the support the submission missed.

Determination & response

Produce a rules-based outcome, a FHIR ClaimResponse, and a plain-language provider determination letter for every case.

Clinician review & audit

Route edge cases to an enforced reviewer workflow with mandatory attribution and reasons, written to an immutable audit log.

Regulatory change monitoring

Optional Regulatory Radar detects policy, coverage, timeline, and reimbursement changes and quantifies their impact on the in-flight PA book.

Who it’s for

• Utilization management teams turning multi-day review queues into sub-minute determinations for clean cases.
• Medical directors and clinical reviewers who want their time reserved for genuine medical-necessity judgement, not clerical review.
• Compliance and regulatory leaders who need transparent, FHIR-based, auditable decisions to meet CMS-0057-F.
• Payer COOs and CMOs scaling PA throughput without adding headcount.

Why it’s different

• Deterministic decisions — the approve / review / request-info outcome is rules-based Python, never the model, so every determination is reproducible and explainable.
• Clinician-in-the-loop by design — an enforced, audited override path keeps licensed judgement on the cases that need it.
• CMS-0057-F ready — FHIR ClaimResponses and a complete audit trail built in, not bolted on.
• Azure-native governance — a Bronze/Silver/Gold estate on OneLake, Entra ID identity, Key Vault secrets, and full Azure Monitor telemetry, run on infrastructure the plan already owns.