AI Prior Authorization for Payers (UM)

These are prior authorization platforms for health plans and other entities that do utilization management. They use AI to automate UM decisions and improve efficiency of UM nurses / clinicians. Functions usually include:  

• Ingestion of clinical policies and translation into decision trees  

• Automatic population of prior auth decisions for approval  

• Automatic approval of auths that meet certain criteria  

• Documentation of decision reasons, i.e. traceable decisions  

Prior authorization vendors vary meaningfully in their service coverage, with some specialized for pharmacy and others focused on certain types of medical services.