Prior Authorization Automation

Your clinicians should not be logging into payer portals. Ailoitte builds automated prior authorization software that pulls the required evidence from the chart, checks it against each payer’s current rules, and submits through whichever channel that payer supports: X12, portal, fax or FHIR. Then it tracks every request to a decision. The clinical call stays with your clinician. Always.

Get a free authorization audit

Send one month of authorization volume, denials included. Within a week: what share can be automated, what your payer mix means for 2027, and the fixed price.

Clinician in the loop

A clinician attests before anything is sent.
Affordable by design

Fixed price from $4,000. No per-request fee.
Every payer channel

X12, portals, fax and FHIR, from one system.

Automated prior authorization software, in six answers.

What we build

Software that gathers the evidence a payer needs, checks it against that payer's rules, sends the request and tracks it to a decision.

What it does not do

Decide whether care is medically necessary, or write clinical justification nobody has reviewed. A clinician attests before submission.

How long it takes

A first specialty and payer set live in 8 to 12 weeks, including EHR integration and that payer's channels.

What it costs

A fixed price per specialty build, $4,000 to $39,000 by scope and AI complexity, quoted after a free audit. No per-request fee.

Which channels

X12 278, payer portals, fax where it is still the only route, and FHIR APIs as payers add them.

What you keep

Code, payer rule data, integrations and the audit trail, assigned to you on payment, with a BAA signed.

Get a free authorization audit Chat on WhatsApp

Sunil Kumar

Co-Founder and CEO @ Ailoitte

What prior authorization automation is, and what it is not.

Prior authorization automation handles the mechanical work around a request. It finds the evidence in the chart, checks it against what the payer wants for that code and plan, sends it, and follows up until a decision arrives. It does not decide whether care is needed. That call stays with your clinicians.

The burden is well measured. In the AMA’s 2025 survey, physicians completed an average of 40 prior authorizations a week, taking about 13 hours. 95 percent said it delays care, and 26 percent said it had led to a serious adverse event for a patient (AMA).

Much of that time is data entry, not judgment: portal logins, copying notes, chasing status. That is the part our prior authorization automation removes. A denial for missing paperwork is a process failure it can prevent.

Already using an authorization tool?

We can check how it handles payers outside the CMS rule, urgent requests and denials, and what it logs for an audit.

Review my current setup

How it works

From chart to submitted and tracked.

Four steps, with the clinician between building the request and sending it. Data work is automated. Clinical judgment is not.

01 Extract the evidence

Notes, labs, imaging and prior therapy
Structured and free-text sources
Nothing inferred that is not in the record
Gaps flagged, never filled

02 Match payer rules

Current rules for that payer, plan and code
Rules held as versioned data
Coverage Requirements Discovery used where offered
Missing items listed before submission

03 Clinician attests

A clinician confirms the clinical content
Edits tracked before anything is sent
No AI-written clinical justification
Attestation stored in the audit trail

04 Submit and track

X12 278, portal, fax or FHIR API
Status written back into the EHR
Urgent requests escalated to a person
Every submission logged

The rule that set a date

CMS-0057-F turned prior authorization into a deadline.

The efficiency case for automating prior authorization is old. The CMS Interoperability and Prior Authorization Final Rule added dates, and half of it is already in force (CMS fact sheet).

Phase one is in force

Since 1 January 2026, covered payers must decide urgent requests within 72 hours and others within seven days. Every denial needs a specific reason.

Metrics are now public

Covered payers must post their approval and timing figures each year, starting 31 March 2026. You can compare them before you negotiate.

Phase two is an engineering deadline

By 1 January 2027, impacted payers must run four APIs, including a Prior Authorization API. The Da Vinci FHIR guides set out how.

Commercial plans are outside it

The rule covers Medicare Advantage, Medicaid, CHIP and plans on the federal exchanges. A system built only for the new APIs would miss much of your work.

Denials

Triaged by reason, not queued by date.

Impacted payers must now give a specific reason for every denial. That reason is often clear enough to route automatically, so each denial goes to the person who can fix it.

Missing documentation

A process failure, not a clinical dispute. It goes straight back for the missing item, and the request is rebuilt, not restarted. Usually the largest group.

Coding mismatch

Routed to coding with the payer's reason and the submitted codes side by side. Repeats on one payer point to a rule data problem, not a coder problem.

Medical necessity

Routed to a clinician for peer-to-peer or appeal. The system assembles the packet from the record. It does not write clinical argument for them.

Data that pays back

Denial reasons and first-pass approval rates per payer and service line. That is the evidence for payer talks and for gold-carding where a payer offers it.

Coverage

Every specialty, every payer mix.

Specialty shapes the build more than most vendors admit, because the evidence each one needs is different.

Oncology

Regimen-level requests, prior therapy evidence and time-critical starts. The hardest specialty to automate well, and the most valuable.

Imaging and radiology

High volumes of fairly structured requests, where first-pass approval moves the numbers most.

Surgery and orthopedics

Authorization on the critical path to an operating room slot, where a delay costs the slot, not just paperwork.

Specialty pharmacy

Repeat authorizations, step therapy evidence and renewals that fail quietly when nobody tracks expiry.

Behavioral health

Extra privacy and consent rules in several states change what may be submitted and how.

Payers and plans

CMS-0057-F APIs, X12 translation, member matching and routing, within the line set out below.

Which of your requests could be automated?

Send a month of requests by specialty and payer, with denials. We will show which share is mechanical work and which needs a person every time.

Sort my requests

How we deliver

From authorization audit to a live specialty, in five stages.

A first specialty and payer set live in 8 to 12 weeks; broader rollouts in 4 to 8 months. Payer rule work is the least predictable part, because it depends on how well each payer documents its own rules. Delivered on Clarity, our delivery method.

Stage 01

Authorization audit

A month of requests and denials sorted by specialty, payer and reason. Your baseline measured: staff minutes per request, time to decision, first-pass approval.

Stage 02

Payer rules and channels

Requirements captured as versioned data per payer, plan and code. Each payer’s channels set up: X12, portal, fax or FHIR.

Stage 03

Build and integrate

Evidence extraction, the attestation step and status write-back built into your EHR. Urgent routing and audit logging in from day one.

Stage 04

Shadow run

Requests assembled beside your current process and compared item by item. Gaps in rule data fixed before any request goes out automatically.

Stage 05

Go live by specialty

One specialty and payer set at a time, with fallback ready. Results reported against your baseline. Then the next specialty.

Where the line sits

The AI does not decide whether care is necessary.

"Chart to approved in minutes" is a good outcome and a dangerous description. Automated denial of needed care is under legal and regulatory pressure, and a vendor offering fully automatic decisions is offering you a problem.

01

California put it in law

Since 1 January 2025, California requires a licensed physician or qualified provider to decide any denial, delay or change of care based on medical necessity. AI cannot be the sole decider (California Senate).
02

Insurers pledged the same

In June 2025, major health plans pledged to cut prior authorization, answer 80 percent of electronic requests in real time by 2027, and keep clinical review of every denial (Healio).
03

Physicians are watching

In the AMA's 2025 survey, 60 percent of physicians said they are concerned that AI increases, or will increase, denial rates (AMA).
04

So the line is fixed

We automate evidence, matching, submission and tracking. Judgments about medical necessity stay with clinicians, on whichever side of the request you sit.

Controls

An automated prior authorization system your compliance team can sign off on.

An authorization record is a financial and clinical document that may be examined years later. We log successful submissions, not only errors, because that is what an audit asks for. See HIPAA compliance and security and compliance.

An audit trail that holds up

What was sent, when and from which chart entries
Which version of the payer rule applied
Who attested to the clinical content
What the payer said back

HIPAA by design

BAA signed before any PHI
Encryption and role-based access
Every access and submission logged
Runs in your own cloud if required

Urgent requests

Flagged at intake
Sent through the fastest channel
A named person if no reply in time
Never left in a retry loop

Measured honestly

Baseline captured before the build
First-pass approval by payer
Avoidable denials tracked
Staff minutes per request

In production

Healthcare platforms we have built.

Care management used by government health plans, EHRs that clinicians actually use, and assistants that take admin work off staff. Prior authorization sits where all three meet. See ROI case studies.

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Pricing

What prior authorization automation costs.

A specialty build costs $4,000 to $39,000, fixed, depending on the payers, channels and EHR involved and how much AI the evidence step needs. Imaging with a few payers on X12 sits toward the low end; oncology across many payers, portals and FHIR sits toward the top.

There is no per-request fee, so cost does not rise with your volume. You own the payer rule data and the authorization history, which matter for payer negotiations and gold-carding. Larger programs across many specialties can run as an AI Velocity Pod from about $15,000 a month.

Stack and integration

The channel is configuration, not architecture.

Your payer mix will not modernize on one date. Portals, fax and X12 will run beside FHIR APIs for years, so each payer’s channel is a setting, and the EHR always gets the status back.

Channels

X12 278, payer portals, fax where required, FHIR Prior Authorization APIs and clearinghouses.

FHIR standards

FHIR R4 with the Da Vinci PAS, CRD and DTR guides, HL7 v2 and SMART on FHIR.

EHRs

Epic, Oracle Health (Cerner), athenahealth, eClinicalWorks, NextGen and Veradigm.

Codes

CPT, HCPCS, ICD-10-CM, SNOMED CT, LOINC and RxNorm.

Payer rules

Versioned per payer, plan and code, with superseded rules flagged.

The hard parts

Member matching, consent, X12 to FHIR fidelity and payer variability.

Security

HIPAA safeguards, BAA, full audit trail and on-premise options.

Reporting

First-pass approval, denial reasons and time to decision by payer.

FAQ

Prior authorization automation, answered.

What is prior authorization automation?

Software that handles the mechanical work around a prior authorization request. It pulls evidence from the chart, checks it against the payer’s current requirements, submits it and tracks it to a decision. Clinical judgment stays with your clinicians.

Does the AI decide whether care is medically necessary?

No, and we will not build that. Medical necessity is a clinical decision. Our system gathers evidence, matches it to documented payer rules and submits. It does not write clinical justification a clinician has not attested to.

What is CMS-0057-F?

A federal rule that sets deadlines for payers. Since 1 January 2026, covered payers must decide urgent requests in 72 hours and others in seven days, and give a reason for each denial. Four APIs follow by 1 January 2027.

Which payers does the rule cover?

Medicare Advantage, Medicaid and CHIP programs and plans, and plans on the federal exchanges. Commercial plans are not covered, so a system that supports only the new APIs will miss part of your volume.

How do you handle different payer channels?

The channel is a setting per payer, not a separate system. The same request can go out as X12 278, through a portal, by fax or through a FHIR API. We follow the Da Vinci guides for FHIR and keep the older channels working.

How do you keep up with changing payer rules?

Rules are stored as data with versions, so a change is a data update, not a new release. We track rules per payer, plan and code, and flag requests sent under an old version.

What happens to denials?

They are routed by the stated reason. Missing documents go back for the item, coding mismatches go to coding, and medical necessity denials go to a clinician. The system builds the appeal packet but does not write clinical argument.

Can it handle urgent requests?

Yes, and urgency changes the routing. Urgent requests are flagged at intake, sent through the fastest channel, and escalated to a named person if no decision arrives in time.

Which EHRs does it work with?

Epic, Oracle Health, athenahealth, eClinicalWorks, NextGen and Veradigm. It reads from the chart and writes the status back, so nobody has to check a separate portal.

Is patient data safe, and do you sign a BAA?

Yes, we sign a BAA and build to HIPAA. Encryption, role-based access, logging of every access and submission, and defined retention. The system can run inside your own cloud if policy requires it.

How long does implementation take?

A first specialty and payer set in 8 to 12 weeks. Expanding across specialties and payers takes 4 to 8 months. Payer rule work is the least predictable part.

How much does an automated prior authorization system cost?

Between $4,000 and $39,000 per specialty build, fixed, depending on payers, channels, EHR and AI. There is no per-request fee. We quote after a free authorization audit.

Do you publish approval-rate or time-saving figures?

No, and be careful with vendors that do. Results depend on your specialties, payers, documentation quality and channels. We measure your baseline first and report against it.

Do you build for payers too?

Yes, within a firm line. We build CMS-0057-F APIs, X12 translation, member matching and routing. We will not build a system that issues adverse decisions on clinical grounds without a qualified reviewer.

Should we buy a platform instead?

Sometimes, and we will say so. If a platform covers your payer mix and EHR well, buying is cheaper. Custom fits unusual specialties, poorly covered payers, hard EHR integrations, or when you need the data in your own analytics.

A question about your own payer mix?

Send it over. A healthcare architect replies within 12 hours.

Ask an architect

Send us one month of your authorization volume.

Include the denials, not just the approvals. A senior architect will tell you what share can be automated, what your payer mix means for the 2027 API deadline, and which specialties should keep a person on every request.

BAA and NDA before we see any PHI
A healthcare architect on the call, not a salesperson
A free authorization audit and fixed price within a week
No obligation, and nothing to pay to find out

Chat on WhatsApp [email protected]

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It's fair to say that we didn't just find a development company, but we found a team and that feeling for us is a bit unique. The experience we have here is on a whole new level.

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Founder & CEO, OpenFactor Technology Group

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CEO, Sanskritly

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Prior Authorization Automation

50M+

3M+

100%

1M+

90%

50M+

3M+

100%

1M+

90%

Automated prior authorization software, in six answers.

What we build

What it does not do

How long it takes

What it costs

Which channels

What you keep

What prior authorization automation is, and what it is not.

Already using an authorization tool?

From chart to submitted and tracked.

01 Extract the evidence

02 Match payer rules

03 Clinician attests

04 Submit and track

CMS-0057-F turned prior authorization into a deadline.

Phase one is in force

Metrics are now public

Phase two is an engineering deadline

Commercial plans are outside it

Triaged by reason, not queued by date.

Missing documentation

Coding mismatch

Medical necessity

Data that pays back

Every specialty, every payer mix.

Oncology

Imaging and radiology

Surgery and orthopedics

Specialty pharmacy

Behavioral health

Payers and plans

Which of your requests could be automated?

From authorization audit to a live specialty, in five stages.

Authorization audit

Payer rules and channels

Build and integrate

Shadow run

Go live by specialty

The AI does not decide whether care is necessary.

California put it in law

Insurers pledged the same

Physicians are watching

So the line is fixed

An automated prior authorization system your compliance team can sign off on.

An audit trail that holds up

HIPAA by design

Urgent requests

Measured honestly

Healthcare platforms we have built.

53M+

100%

50M+

1.1B $

35%

40%

3M+

1.5M+

90%

1M+

90%

10%

42% +

3.5x

What prior authorization automation costs.

The channel is configuration, not architecture.

Channels

FHIR standards

EHRs

Codes