Agentic Prior Authorization

Interoperable AI agents that automate, accelerate, and simplify prior authorization—reducing delays, minimizing denials, and improving patient care.

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Inspiration

Prior authorization is one of the most time-consuming and frustrating processes in healthcare, often causing treatment delays and administrative burden for providers. Inspired by emerging AI agent architectures, we aimed to reimagine prior authorization as an intelligent, automated, and interoperable workflow that reduces friction and improves turnaround time.

What it does

The AI-Powered Prior Authorization Orchestration Agent automates the complete prior authorization lifecycle using four specialized AI agents working together: Eligibility Verification Agent — Instantly checks insurance coverage and determines whether prior authorization is required Clinical Documentation Agent — Extracts, validates, and structures clinical notes, diagnostic reports, and patient history Prior Authorization Submission Agent — Works as an orchestrator between other AI agents. Monitoring & Follow-up Agent — Continuously tracks authorization status and updates patients, physicians, and hospital staff automatically

How we built it

We built a multi-agent architecture where each AI agent specializes in a specific function—data extraction, policy validation, and workflow orchestration.
Using Generative AI, the system interprets clinical documents (text-based pdfs in our case) and translates them into structured, payer-ready submissions. Prompt Opinion's UI enable interoperability between agents with optional FHIR context.

Challenges we ran into

  • The biggest challenge was handling the variability in payer rules and unstructured medical data. Ensuring accurate interpretation while maintaining compliance required careful prompt engineering and validation layers. Another challenge was orchestrating multiple agents together

Accomplishments that we're proud of

  • Automated a traditionally manual and error-prone workflow
  • Demonstrated interoperability across multiple AI agents
  • Reduced simulated prior authorization turnaround time
  • Created a scalable architecture adaptable to different payers

What we learned

We learned how powerful AI agents can be when orchestrated effectively for complex workflows. The importance of combining Generative AI with rule-based validation became evident, especially in regulated domains like healthcare. We also gained insights into designing systems that balance automation with reliability and explainability.

What's next for AI-Powered Prior Authorization Orchestration Agent

Next, we aim to integrate real-world payer APIs, enhance compliance and auditability, and incorporate predictive analytics to anticipate authorization outcomes. We also plan to expand the system to support broader revenue cycle management workflows and real-time decision support for providers.

Built With

  • a2a
  • mcp
  • promptopinion
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