16 AI Agents.
One Prior Auth Platform.

Reads electronic prescriptions, faxes, paper, and phone orders. Uses OCR, Vision models, and LLM extraction to capture drug, strength, quantity, directions, prescriber, and insurance details.

The first intelligent decision point. Checks PBM reject codes, DUR messages, NCPDP responses, and plan formulary to determine if prior authorization is required.

Automatically checks BIN, PCN, Group, Member ID, coverage status, and preferred drug. Detects step therapy requirements, quantity limits, age restrictions, and diagnosis restrictions.

Reads payer-specific requirements for the prescribed drug. For Ozempic: needs Type 2 diabetes diagnosis, HbA1c value, Metformin failure. Identifies exactly what documentation is missing.

Collects medication history, fill history, allergies, previous therapy failures, ICD-10 codes, lab values, and progress notes from Pharmacy Management System, EHR, and Health Information Exchange.

Auto-generates fax, portal message, phone script, or email requesting exactly what the payer needs. Example: "Patient requires PA for Ozempic. Please send: Diagnosis, Recent A1c, Previous medications, Clinical notes."

If physician hasn't responded: Day 1 reminder, Day 2 call, Day 4 portal reminder, Day 6 escalation. Fully automated — no human needed unless necessary.

Automatically opens CoverMyMeds, electronic PA portals, or insurance portals. Fills patient, drug, diagnosis, provider, history, and clinical notes. Uploads PDFs. Saves several minutes per PA.

Uses LLM to generate medical necessity letter, clinical summary, prior treatment history, and supporting rationale. Example: "Patient has failed Metformin, Glipizide, Jardiance. Current HbA1c 9.4%. Ozempic is medically necessary."

Submits through ePA, CoverMyMeds, fax, or insurance portals. Logs confirmation number, timestamp, and expected response window for full audit trail.

Runs every few hours. Checks pending, approved, need-more-info, denied, and expired statuses across all portals simultaneously — instead of staff logging into multiple portals manually.

On approval: automatically updates pharmacy software, reverses claim, rebills, prints label, notifies technician, and notifies patient. Zero manual steps required.

Reads denial reason — missing labs, wrong diagnosis, step therapy requirement, coverage exclusion — and generates an optimal appeal strategy with highest likelihood of success.

Auto-drafts complete appeal letter with medical necessity argument, supporting evidence, clinical guidelines, peer-reviewed references, and documentation of prior treatment failures.

Automatically sends SMS, email, or automated phone call at every status change. "Your prior authorization was approved." or "We are waiting for your doctor's office." Patients always informed.

Tracks average approval time, revenue recovered, top rejected drugs, top slow physicians, top slow insurance companies, PA completion rate, technician productivity, and money recovered. A powerful dashboard for pharmacy owners.