Prior Authorization with Agentic Process Automation for a Specialty Infusion Provider
Less Staff Effort per Request (45 to 10 minutes)
First-Pass Approval Rate (up from 78%)
Fewer Denials (22% to 7%)
Industry
- Healthcare
Processes Automated
- Order intake and classification
- PA requirement check
- Clinical evidence matching
- Payer submission and tracking
- Exception review
Automation Highlights
- Document AI Agent (IDP) reading faxes, referrals, and clinical notes
- AI agents checking PA requirements and matching evidence to payer criteria
- Agents submitting and tracking requests across payer portals and APIs
- Humans in the loop for low-confidence cases
A Specialty Infusion Provider
A specialty infusion provider treats thousands of patients a month across dozens of sites. Most infusion drugs need payer approval before the first dose, so prior authorization (PA) stands between most referrals and the start of therapy. Manual PA work, from re-keying data into payer portals to chasing status by phone, delayed therapy starts and drove avoidable denials.
Nividous runs the full PA process in one governed workflow, from order intake to payer decision. The Document AI Agent (IDP) reads incoming documents, AI agents make the judgment calls, Agents handle payer submission and tracking, and humans review exceptions.
Illustrative scenario: figures are modeled on 4,000 PA requests a month, not measured customer results.
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