Prior authorization support that proves every payer criterion from the chart before the request goes out
Each payer criterion proven from the chart, so therapy starts in days.
See one case, screen by screen ↓The work of getting a payer's approval for a prescribed therapy: proving each medical-necessity criterion from the chart, filling the payer form or ePA question set, writing a letter of medical necessity, submitting and following up. Prior Authorization Support does that in the prescriber's office with six agents that match every criterion to the chart passage that proves it and build a cited pack. The prescriber reviews and e-signs.
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For a biologic or a targeted oral therapy, the payer's medical-necessity policy lives in a PDF and the evidence lives in 20 to 60 chart pages. A PA coordinator reads the policy, hunts the chart for each criterion — diagnosis, severity, prescriber specialty, step therapy, TB screening — fills the payer form or the ePA question set, and writes a letter of medical necessity. Criterion by criterion, from memory and a highlighter.
The risk is the evidence that is not in the exported chart: a telehealth visit, an outside lab, a fill at a retail pharmacy. A step-therapy line looks unmet, the request goes out anyway, and the office learns it from a denial letter weeks later — while the patient waits to start therapy. Templated letters that claim more than the chart supports cost the prescriber credibility with the payer.
Estimated hours of office work on a typical specialty-drug request, by hand and with the solution. Waiting for the payer is not counted.
Five agents match the chart to each payer criterion and build a cited pack; the prescriber signs, and a sixth agent watches the payer's clock.
Dr. Maya Chen at Lakeshore Dermatology & Rheumatology prescribes Veltrimab for Jordan Reyes, 41, who has had plaque psoriasis since 2019. His payer, Crestline Health, has six criteria. Here is what happens next, screen by screen, in the working solution.
Jordan's chart arrived at 07:52: 46 pages, 8 documents. Priya opens his request against Crestline Health policy CHP-RX-118 v2026.10, Commercial. Each of the six criteria is shown in the payer's own words — diagnosis, severity, prescriber, two step-therapy lines and safety — with the verdict and the chart evidence still empty. Across the top are the morning's other requests, each with its count and state.
The pack waits: “Prescriber e-signature — nothing goes to the payer before it.”
The Chart Reader reads 46 pages and 8 documents in 38 seconds, every fact with its page. The Therapy History Builder finds 3 prior therapies and checks the dates against pharmacy fills in 6 seconds. The Criteria Matcher takes the six criteria of CHP-RX-118 line by line in 11 seconds, and each line lands with its verdict and confidence.
Line 1 lands first: met, 97% sure — plaques since 2019, DOB 03/14/1985, page 1 and page 4.
BSA 14% including scalp and both palms on the Sep 22 note, page 24. Board-certified dermatologist, 150 mg at weeks 0 and 4 then every 12 weeks. Fifteen weeks of Tenzira with no meaningful response, confirmed by 4 fills. A negative IGRA from Oct 3. But line 4 — methotrexate for 3 months or more — is unmet: topicals for 8 weeks and UVB for 12 weeks are documented, and no methotrexate, cyclosporine or acitretin appears in the 46 pages or the specialty pharmacy fills.
“No documented trial of methotrexate.” A gap is never marked met.
Crestline's policy makes the systemic step specific, and Priya approved that change on Oct 1: at least 3 months of methotrexate, documented in a visit note. That is the rule that flagged Jordan's request. The matcher only uses approved policy versions — the new version Crestline sent on Oct 6 waits until a person approves it.
Priya presses Search the practice record on line 4. The agents look at telehealth encounters and outside pharmacy claims for his MRN since 2024. They find 2 telehealth visits with Dr. Chen on Jan 6 and May 12, 2026 that were not in the chart export, and 5 methotrexate fills at a retail pharmacy from Jan 6 to Apr 29, 2026.
Found: “Methotrexate 15 mg weekly · 18 weeks — inadequate response.”
Attached, the chart is now 51 pages and line 4 is met at 99%: 18 weeks of methotrexate, stopped for inadequate response and ALT 2.4 times the upper limit. One click builds the pack from the proven lines only: the payer form at 32 of 32 fields, the ePA question set at 14 of 14, a one-page letter of medical necessity in Dr. Chen's voice with 13 citations, and 17 of 51 chart pages, passages highlighted.
The letter: “every statement cited.”
The review shows 6 of 6 criteria proven, the form, the letter and 9 cited documents. Dr. Chen ticks the attestation — she has reviewed the request, the letter and the attached records, they are accurate, and Veltrimab is medically necessary for this patient — and signs. She can also send it to her signature folder for later.
“Nothing is sent to Crestline Health until you sign.”
The form, the letter and 17 cited pages go to Crestline Health by ePA. Four minutes later the Status Watcher records the decision: approved, CH-26-884213, valid 6 months to Apr 6, 2027 — 0.7 days from prescription. Jordan can start Veltrimab.
“Approved — every criterion met on first review.”
Theo Lindqvist, 67, needs Veltrimab for Crohn's disease under Silverpine Medicare Advantage — expedited, a 24-hour decision once submitted. Six of 8 lines are met. His liver tests are from Apr 28, 162 days ago, older than the 90 days Silverpine allows: one click orders a liver panel for Dr. Ortiz. Steroid dependence is stated without taper dates, at 84% confidence, so it waits for a person to confirm.
“Steroid dependence stated, taper dates not recorded — a person confirms below 90%.”
The same request, seen by the four people who carry it at the practice — what their week looked like, and what it looks like now.
Five agents match the chart to each payer criterion and build a cited pack; the prescriber signs, and a sixth agent watches the payer's clock.
Reads every chart page — visit notes, labs, prescriptions, fill history — classifies it and pulls out diagnoses with ICD-10, severity scores, drugs with dose and dates, and lab results with collection dates, each with the page it came from.
Builds the prior-therapy timeline — drug, dose, start, stop, weeks, outcome and reason stopped — and checks the dates against pharmacy fills.
Takes every criterion of the approved payer policy and returns met, unmet or unclear, the passages that decide it, the option used for either-or criteria, its reasoning and a confidence. Below 90% confidence, a person checks.
Fills the payer's prior authorization form and answers the ePA question set from the proven evidence, each answer cited, and attaches the cited pages.
Drafts the one-page letter of medical necessity — and appeal letters — in the prescriber's voice: the request, diagnosis and severity, a treatment-history table, the clinical rationale and safety, every clinical statement cited.
Submits after signature, tracks the payer's clock and decision, turns a request for information into a cited reply draft and a denial into an appeal draft.
Reviews and signs. The agents propose; a named person decides.
Ask about any request, payer rule or chart — or say what to change. Answers cite the chart page.
What's blocking Jordan Reyes's Veltrimab request?
One line: no documented trial of methotrexate. Crestline needs at least 3 months of methotrexate (or cyclosporine or acitretin) after topicals. The 46 pages show topicals for 8 weeks and UVB for 12, but no methotrexate. Dr. Chen held two telehealth visits this year that the chart export leaves out — Search the practice record on line 4 finds them. The other five lines are met.
Which requests can the prescribers sign today?
Two requests are complete and only need a signature: Alicia Moreno for Corventa, 9 of 9, with Dr. Haddad, and Grace Whitfield for Veltrimab, 6 of 6, with Dr. Chen. Grace Whitfield's renewal matters most — her current approval ends Oct 14.
Why was Rafael Duarte denied, and can we appeal?
Northgate Rx denied Corventa on Sep 30 because “the records show a TNF blocker trial of 8 weeks”. They read the week-8 check-in. The Sep 15 note records 14 weeks of Tenzira with inadequate response, and four 28-day fills from Jun 9 to Sep 1 confirm it. The appeal answers exactly that, with both pages cited — the Letter Drafter writes it in one click and Dr. Haddad signs it.
Flag any lab result older than 11 months
Done. The evidence rule is now 11 months — stricter than Crestline's 12, so it wins for every payer. Nothing new is flagged today; Theo Lindqvist's TB test from Jun 2 is the next to cross the line. The change is in Settings and on the audit trail.
13 screens from the working solution, on its sample data. Pick one to see it large.
How requests are signed and how evidence is judged are settings, and every change is recorded in the audit trail.
| Setting | Default | Choose from |
|---|---|---|
| Prescriber signs every request | Locked on | Always on — nothing goes to a payer without the prescriber's e-signature |
| Draft the letter as soon as gaps close | Off | On · Off (the coordinator starts the Letter Drafter once every criterion is proven) |
| Who may press submit after signing | Prescriber or coordinator | Prescriber or coordinator · Prescriber only |
| Flag lab results older than | 12 months | Step up or down a month at a time — the stricter of this and the payer's window wins |
| Confirm therapy dates with pharmacy fills | On | On · Off |
| A person checks a match below | 90% confidence | 85% · 90% · 95% confidence |
| Sharing with the manufacturer's support program | Status only, with consent | Status only, with consent · Off |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published prior-authorization surveys (2024–25): 17 days by phone and fax, as little as 1.5 days electronically. People, practices, payers, products and patients named on this page are fictional — characters and sample data in the working solution.
The work of getting a payer's approval for a prescribed therapy: proving each medical-necessity criterion from the chart, filling the payer form or ePA question set, writing a letter of medical necessity, submitting and following up. Prior Authorization Support does that in the prescriber's office with six agents that match every criterion to the chart passage that proves it and build a cited pack. The prescriber reviews and e-signs.
The Chart Reader reads every page and extracts facts with their page. The Therapy History Builder builds the prior-therapy timeline and checks it against pharmacy fills. The Criteria Matcher then takes each criterion of the approved payer policy and marks it met, unmet or unclear, with the passages that decide it and a confidence.
The line says what is missing and what was checked, on day one instead of in a denial letter. The agents can search the practice record — telehealth visits, outside pharmacy claims — for the missing evidence, a test can be ordered, or the prescriber can be asked. The pack cannot be built until every line is proven.
Yes. The Letter Drafter writes a one-page letter in the prescriber's voice from the proven lines only — the request, diagnosis and severity, a treatment-history table, the clinical rationale and safety — with every clinical statement cited. It also drafts appeal letters that answer the denial reason. The prescriber edits and signs.
The practice owns and controls every request and the prescriber decides what is sent. With the patient's signed consent, the manufacturer's support program can see a request's status only — never chart pages, letters or forms. It does not submit and does not edit clinical content.
Yes. Nothing goes to a payer without the prescriber's e-signature, a setting that is locked on. The coordinator confirms unclear lines and closes unmet ones, a person approves every new payer policy version, and every action by a person or an agent is on the audit trail.
Yes. The practice sets how old a lab result may be (the stricter of its rule and the payer's window wins), whether therapy dates must be confirmed with pharmacy fills, the confidence below which a person checks a match, who may press submit after signing and whether the letter is drafted as soon as gaps close.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your payers' medical-necessity policies, their forms and a sample of past requests — and it goes live once every quality gate has passed. We will walk you through it on your own requests first.
Every enrollment form becomes a complete hub case in minutes, gaps faxed back same hour.
1-min demoPatient Assistance Program EligibilityEvery application checked against every rule, most decided within a day.
1-min demoBenefits Investigation & VerificationCoverage checked across sources and summarised within a day.
1-min demoWe'll run Prior Authorization Support on a sample of your own past requests and the payer policies behind them.