Prior-Auth Agent — Automated Prior Authorization
Gathers clinical data, submits to payers, and tracks authorizations to approval — inside your own environment.
Stop Losing Days to Prior Auth
Prior authorization is manual, slow, and a leading cause of care delays and staff burnout. The Prior-Auth Agent handles the paperwork end to end — detecting requirements, assembling evidence, submitting, and chasing status — so approvals come back faster and cleaner.
70%+
Automated
Requests prepared and submitted without staff
Days → Hrs
Faster approvals
Turnaround cut across the board
Fewer
Denials
Complete, criteria-matched submissions
HIPAA
Ready by design
Runs inside your own environment
Prior-Auth Agent Architecture
The Platform, Specialized for Authorizations
The Prior-Auth Agent runs on the same base Vervelo Agents Platform architecture as every other agent — here, a durable runtime submits and tracks authorizations against payers, a streaming runtime handles status checks and inquiries, and the connected tools are the payer, EHR, and clinical-criteria systems prior auth depends on.
Context Engineering
Engineered Context, Every Turn
Reliable agents aren't a single clever prompt — they're the product of context engineering: assembling exactly the right information into the model's context window on every turn. It's the discipline we build every Vervelo agent around. Here's what the Prior-Auth Agent works from on each turn, and how we engineer it.
Prior-Auth Agent context window
Assembled fresh on every turnSystem Instructions
The prior-auth specialist persona and rules — payer-specific requirements, what counts as a complete request, and never to submit without the required evidence.
Tool Definitions
Payer submission (portal / X12 278), EHR retrieval, and status-check tools with strict schemas for clean, valid transactions.
Memory & User State
Per-payer and per-case state — plan rules learned over time, prior determinations, and standing submission preferences.
Conversation History
The case timeline — every submission, payer response, and follow-up — so the agent knows exactly where each authorization stands.
Retrieved Knowledge
Policy vectors — payer medical-necessity criteria and clinical guidelines — retrieved to assemble a compliant, defensible packet.
Environment Results
Payer responses, submission acknowledgements, and denials or errors, parsed so the agent can track, appeal, or escalate.
Capabilities
The Whole Authorization Workflow, Handled
Requirement Detection
Flags which orders and referrals need prior authorization, and for which payer and plan.
Clinical Data Gathering
Pulls the notes, labs, and imaging that justify medical necessity straight from the EHR.
Payer Submission
Submits via payer portals and X12 278 transactions, packaged to each payer's rules.
Status Tracking & Follow-up
Polls status, chases pending cases, and answers inbound payer inquiries automatically.
Denial & Appeal Support
Identifies denial reasons, gathers missing evidence, and drafts appeals for review.
Full Audit Trail
Every request, document, and payer response is logged for compliance and reporting.
How it works
From Order to Approval
01
Detect
Spots orders that need authorization and identifies the payer, plan, and criteria.
02
Gather
Collects supporting clinical documentation from the EHR to prove medical necessity.
03
Submit
Packages and submits the request via portal or X12 278, matched to payer rules.
04
Track
Monitors status, follows up on pending cases, and handles payer inquiries.
05
Resolve
Secures approval — or gathers evidence and drafts appeals for denials — with a full audit trail.
Powered by the Vervelo Agents Platform
Open Source. On Your Infrastructure.
The Prior-Auth Agent is built on our open-source platform — deployable in your cloud, on-prem, or air-gapped — so PHI and payer data never leave your environment.
Compliance-First, Protecting Patient Data
The Prior-Auth Agent is built with HIPAA-ready security, audit logging, and safe handling of clinical and payer data — aligned to HIPAA, GDPR, SOC 2, and HL7 FHIR — so you can automate authorizations with full accountability.
Vervelo is a digital-health software partner blending deep clinical insight with world-class engineering to build tailored, secure, interoperable healthcare platforms.
Benefits of custom software solutions
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You fully own IT consulting and software delivered
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You get a highly personalized solution
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Customize and integrate seamlessly
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On-demand scalability is always possible
