AI Prior Authorization for Payers

Automate Authorization Reviews with HealOS

Prior authorization is one of the most resource-intensive workflows for payers. Manual reviews, inconsistent documentation, and growing request volumes slow decisions, increase administrative costs, and frustrate providers and members. HealOS delivers AI-powered prior authorization automation built for payers. Our platform automates intake, clinical validation, policy enforcement, and decision support, helping payers process authorizations faster, more consistently, and at scale. This is modern AI authorization software designed for payer operations.

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Why Prior Authorization Is Broken for Payers Today

Payer authorization teams face rising volume and complexity.

Manual intake from portals, faxes, and attachments

Inconsistent medical necessity documentation

Policy interpretation variability across reviewers

Long turnaround times and backlog

High administrative costs per authorization

Poor visibility into reviewer performance and bottlenecks

Traditional workflows cannot scale with today’s utilization demands. Automation is no longer optional for payers.

HealOS for Payer Prior Authorization

HealOS is an AI prior authorization solution for payers designed to automate authorization workflows from intake to decision. It connects provider submissions, clinical data, and policy logic into one intelligent system, reducing manual work while improving speed, consistency, and compliance.

~21 Days

Typical Go-Live Timeline

85%+ of Requests Auto-Processed

Authorization Automation Coverage

100% Pilot Graduation

Deployment Conversion Rate

How HealOS Automates Prior Authorization for Payers

Step 1

Authorization Intake & Normalization

HealOS ingests authorization requests from portals, APIs, fax, and attachments, normalizing data into structured authorization records automatically.

Step 2

Clinical Documentation Analysis

HealOS analyzes submitted clinical documentation using AI to assess completeness, relevance, and medical necessity against payer policies.

Step 3

Policy & Rule Enforcement

HealOS applies payer-specific policies, coverage criteria, and utilization rules consistently across all authorization requests.

Step 4

Decision Support & Auto-Adjudication

HealOS recommends approval, denial, or pend decisions with supporting evidence, enabling straight-through processing or rapid reviewer decisions.

Step 5

Communication & Audit Logging

HealOS updates provider portals, sends decision notifications, and maintains full audit trails for compliance, appeals, and reporting.

Core Capabilities for Payer Prior Authorization

Case Intake & Intelligent Triage

HealOS automatically ingests 278 transactions and attachments, normalizes authorization data, and routes cases by urgency, service type, and line of business.

Clinical Guideline Matching

HealOS cross-checks submitted documentation against clinical guidelines, flags exceptions, and assembles complete authorization packets for efficient human review.

Automated Determinations & Notifications

HealOS generates authorization determinations with clear clinical rationale and delivers provider notifications with full audit trails and decision transparency.

Continuous QA & Regulatory Reporting

HealOS scores decision accuracy and turnaround time per run, exporting detailed logs to support CMS, state, and internal utilization management reporting.

Measurable Impact for Payer Operations

See real operational improvements with AI-driven authorization automation.

60%

Faster Authorization Turnaround

50%

Reduction in Manual Reviews

90%

Reliability on end-to-end workflows

90%

Accuracy across automated cases

Who HealOS Is Built For

Hospitals & Health Systems

Handle high inbound call volumes across departments and facilities.

Physician Groups

Reduce front-desk overload and missed appointment opportunities.

Behavioral Health Providers

Provide discreet, always-available call handling for sensitive patient needs.

Specialty Clinics

Manage complex scheduling and referral calls efficiently.

Telehealth Providers

Support virtual-first patient access with automated appointment scheduling.

Security & Compliance

HIPAA Compliant

Secure PHI handling without storage

SOC 2 Type II Certified

Independently audited enterprise security

Secure Authentication

SSO and multi-factor access controls

Frequently Asked Questions

Start Automating Prior Authorization for Payers

HealOS delivers AI-powered prior authorization automation for payers, reducing turnaround time, administrative cost, and operational friction.

Book a HealOS Demo