A Fortune 500 healthcare payer transformed prior auth from a clinician backlog and patient pain point into a triaged, AI-assisted workflow — without making a single clinical decision the system shouldn't be making.
Prior authorization (PA) — the insurance-side approval step before a clinician can proceed with a treatment, test, or procedure — is the most painful workflow in US healthcare for clinicians, for patients, and for the payers running it. A Fortune 500 healthcare payer was processing millions of prior auth requests per year, with clinical reviewers buried in repetitive documentation review and policy lookups. Patients waited days for decisions. Clinicians stopped trusting the system. The payer needed AI that could safely automate the routine cases, surface the high-judgment cases to clinicians faster, and never make a clinical decision the system shouldn't be making.
BizzSoftware partnered with the payer's Utilization Management and Clinical Operations teams to design and build an AI-assisted prior authorization application. Three principles drove the design:
AI handles parsing, lookup, and routine approvals. High-judgment cases route to clinicians faster, with all evidence pre-organized.
Every AI decision logged with full chain of evidence — supporting regulatory and audit obligations.
UM nurses and physicians use the system thousands of times per shift. Built around speed and clarity.
Incoming prior auth requests parsed, classified, and routed; routine cases auto-approved against verified criteria, complex cases pre-prepared for clinician review.
UM nurses and physicians work cases with all relevant clinical and policy evidence surfaced in context.
Full decision lineage on every output, supporting regulatory, audit, and quality review.