Prior authorization
Payer rules searched, clinical evidence gathered and the packet ready to submit within minutes of the order.
Prior authorization is an agent scenario in the Healthcare sector running on the api, email, web channels. Trigger: A procedure order requiring prior authorisation is placed in the EHR. The Prior Auth Supervisor coordinates 3 specialist agents (Order Agent, Payer Rules Agent, Submission Agent) across 4 systems (EHR (HL7/FHIR), Payer Policy Vector Store, Payer Portal, Exchange / M365 Mail); of 10 steps, 2 write to systems and 2 are checks or approvals. Outcome: Complete packet submitted to the payer, auth number written to the EHR, team informed. Approval rule: Surgical procedure or cost > 25,000 TL → utilisation management nurse approval.
Prior authorization
- Order OR-58213 for lumbar fusion received from the EHR, patient identity matched
- CPT 22612 · ICD-10 M43.16 · Physician: Dr Yılmaz · Payer: Plan A · Cost 185,000 TL
- Plan: clinical notes → payer rule → necessity check → submit
- Last 6 months of notes, MRI report and 8 weeks of physiotherapy records pulled
- Payer policy SP-L-2026 §4.2 found: ≥ 6 weeks of conservative treatment required
- Necessity: 8 weeks PT documented, neurological deficit present → criteria met (0.93)
- Surgical procedure → utilisation management nurse reviewed and approved the packet
- Packet (12 pages) submitted to the payer portal, reference PA-2026-118402 received
- Authorisation number and 90-day validity written to the encounter
- Physician office and surgical scheduling informed, decision trail stored
- ■completed
Simulation · derived from real agent definitions · every agent can be built by dialogue with the Autonomous Agent and validated with a test corpus
A procedure order requiring prior authorisation is placed in the EHR
Complete packet submitted to the payer, auth number written to the EHR, team informed
Agents
Prior Auth Supervisor
Decomposes the objective, delegates to agents, manages approval points, merges the result.
Order Agent
Extracts fields from the order and clinical documents
extract_order_fieldsextract_clinical_notesPayer Rules Agent
Searches payer policy and assesses medical necessity
search_payer_policycheck_medical_necessitySubmission Agent
Assembles the packet, submits it and updates the record
build_auth_packetsubmit_prior_authupdate_encountersend_emailSteps
| # | Kind | Agent | What happens | System | ms | tok |
|---|---|---|---|---|---|---|
| 01 | ingest | Prior Auth Supervisor | Order OR-58213 for lumbar fusion received from the EHR, patient identity matched | — | 200 | — |
| 02 | reason | Order Agent | CPT 22612 · ICD-10 M43.16 · Physician: Dr Yılmaz · Payer: Plan A · Cost 185,000 TL | — | 720 | 640 |
| 03 | plan | Prior Auth Supervisor | Plan: clinical notes → payer rule → necessity check → submit | — | 300 | 210 |
| 04 | retrieve | Order Agent | Last 6 months of notes, MRI report and 8 weeks of physiotherapy records pulled | EHR (HL7/FHIR) | 460 | — |
| 05 | retrieve | Payer Rules Agent | Payer policy SP-L-2026 §4.2 found: ≥ 6 weeks of conservative treatment required | Payer Policy Vector Store | 520 | 880 |
| 06 | verify | Payer Rules Agent | Necessity: 8 weeks PT documented, neurological deficit present → criteria met (0.93) | — | 840 | 1,100 |
| 07 | approval | Prior Auth Supervisor | Surgical procedure → utilisation management nurse reviewed and approved the packet | — | 2,600 | — |
| 08 | write | Submission Agent | Packet (12 pages) submitted to the payer portal, reference PA-2026-118402 received | Payer Portal | 900 | — |
| 09 | write | Submission Agent | Authorisation number and 90-day validity written to the encounter | EHR (HL7/FHIR) | 380 | — |
| 10 | notify | Submission Agent | Physician office and surgical scheduling informed, decision trail stored | Exchange / M365 Mail | 240 | — |
Patient journey coordinator: appointment, preparation, approval and results
The patient writes or calls; appointment, preparation instructions, insurer pre-approval and result notice come together in one coordinator.
Patient intake and triage
The patient types or talks; intake and urgency scoring take seconds, and a nurse always makes the final call.
Appointment scheduling and no-show reduction
High no-show-risk patients are reached on WhatsApp in advance; freed slots are refilled from the waiting list.
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