Example agent design
Prior Authorization & Denial Agent for Practices
A prior authorization and denial agent verifies coverage before the visit, checks whether each service needs authorization, assembles a cited payer packet from only the chart elements each criterion allows, and drafts denial appeals for staff approval. This is a starting design. An AI Blueprint adapts it to your goals and the systems it will connect to.
- Owner
- The authorization coordinator and revenue cycle lead. Clinicians sign any letter of medical necessity.
- Reads
- Schedules, orders, referrals, and insurance from the practice management system · Eligibility, claim status, and remittances through the clearinghouse · Only the chart elements each payer criterion allows · Payer policies, gold-card notices, and payer letters
- Never writes
- Clinical or medical-necessity determinations, or any change to clinical documentation. No submission, appeal, adjustment, or write-off without a named person's approval, and no PHI sent outside the business associate agreement chain.
- Typical cost
- Custom-scoped. Quoted after scoping. See the first engagement
The workflow
Authorizations and denials today and with the agent
Planning comparison only. Scope, timing, and outcomes vary by data, workflow, approvals, adoption, and implementation conditions.
- Coverage
- TodayChanges found at check-in instead of before the visit.
- With the agentChecked at scheduling and again 72 hours before the visit, with problems routed to the front desk.
- Authorization rules
- TodayDiffer by payer, plan type, and site, and are looked up by hand.
- With the agentEach scheduled service marked required, not required, exempt, or unknown from a maintained payer-rules library.
- Packets
- TodayAssembled by hunting through the chart.
- With the agentBuilt from only the chart elements each payer criterion allows, with each criterion cited.
- Status checks
- TodayBy phone, portal, and fax.
- With the agentThe payer's response clock tracked for each request.
- Denials
- TodayWorked in arrival order, with appeal deadlines in spreadsheets.
- With the agentRanked by value and appeal deadline, with appeals drafted for approval.
How it runs
Five steps from schedule to submission and appeal
An illustrative solution design, not a reported client result. The agent is administrative only: it compares documentation already in the chart with published payer criteria and leaves clinical and payer decisions with a named person.
Verify coverage before the visit
The agent runs eligibility checks when a visit is scheduled and again 72 hours before it, normalizes the plan type, and routes coverage, network, and coordination-of-benefits problems to the front desk.
Check whether authorization is required
A maintained payer-rules library returns required, not required, exempt, or unknown for each scheduled service, including Texas gold-card exemptions and the Medicare prior-authorization programs that began in Texas in 2026.
Assemble a cited packet
It retrieves only the chart elements each payer criterion allows, links each criterion to its evidence or marks it as a gap, and drafts the request and any letter of medical necessity for clinician signature.
Staff and clinicians approve
The authorization coordinator approves or edits the packet and the clinician signs any letter. Staff submit through the payer API, portal, or fax, and the agent tracks the payer's response clock.
Human approval point
Work denials and learn
It ranks returned denials by value and appeal deadline and drafts appeals that cite the payer's stated reason. Write-offs need approval, and root causes become proposed front-end rule changes for staff approval.
Human approval point
Systems
The systems it reads
Payer prior-authorization APIs help where they exist. This design covers what they do not: chart evidence, state-regulated and self-funded plans, and denial work.
- Practice management and EHR
- Schedules, orders, referrals, and only the allowed chart elements, from athenahealth, eClinicalWorks, NextGen, ModMed, Greenway, Dentrix, or Open Dental.
- Home health
- WellSky or Homecare Homebase, for home health providers.
- Clearinghouse
- Eligibility, claim status, and remittances through Waystar or Availity.
- Payer sources
- Payer policies, gold-card notices, and payer letters from fax and portals.
Technologies ITECS evaluates and integrates; listing a product does not imply a formal partnership or a certified integration. Scoping confirms the systems and interfaces each practice runs.
Controls
Read-heavy and write-controlled by design
- Read-heavy
- Reads the systems listed above through access scoped to this workflow.
- Write-controlled
- Writes nothing listed under Never writes in the spec at the top of this page. Anything it drafts waits at the approval points below.
- Approval points
- The authorization coordinator approves or edits each packet, clinicians sign any letter, and staff submit. Write-offs need approval.
- Audit trail
- Each run keeps its inputs, sources, output, and the reviewer's decision.
In this design
- The agent is administrative only. It compares documentation already in the chart with published payer criteria, shows each match or gap with a citation, and sends gaps to clinicians as non-leading queries.
- Every service that touches PHI sits inside the business associate agreement chain: the practice, ITECS, and each model or cloud subcontractor.
- Retrieval is limited to the minimum each task needs, with field-level access logs showing which records were used.
- Texas AI disclosure duties are part of the design, and counsel confirms the wording of the practice's notice.
- ITECS does not provide medical or legal advice through its agents, and no design promises an outcome. The agent prepares and flags; the practice's staff and clinicians decide.
Deployment fit
Where this design can run
- Hosted AI Agents
- Runs in a governed environment ITECS operates, only on services listed as eligible under a business associate agreement, connected to the practice management system, the EHR, and the clearinghouse through controlled integrations, with human review and an audit trail.
- Private AI Servers
- Runs on local models on a server inside your network, for protected health information that should stay on it. Regulated builds are custom-scoped, and server hardware is quoted after a sizing call.
Typical first engagement
Custom-scoped for regulated work
Regulated work is custom-scoped on compliance-eligible platforms, with the compliance framework governing the architecture. Standard packages do not apply to these engagements.
- Scoping
- Starts from an AI Blueprint request. Strategist-led scoping maps the protected data, the agreements each service needs, and the compliance framework before any build.
- Platforms
- Only services the vendor lists as eligible under a business associate agreement.
- Price
- Quoted after scoping. The published packages and their prices do not apply.
- After launch
- Operating the agent after launch is scoped with the build.
Customize this design
Bring your goals and your systems through an AI Blueprint request. For regulated work the engagement is then custom-scoped and quoted, and the scoping decides the systems and the build, not this example.
FAQ
Prior Authorization & Denial Agent FAQ
Will the AI decide medical necessity or change clinical notes?
No. The agent compares documentation already in the chart with the payer's published criteria and shows each match or gap with a citation; clinicians sign any letter of medical necessity, and staff approve each submission.
Do we need a BAA with ITECS and with the AI vendor?
Yes. Any service that creates, receives, maintains, or transmits PHI for you is a business associate, including the model provider ITECS uses as a subcontractor; ITECS includes a BAA for healthcare clients and runs agents only on services the vendor lists as BAA-eligible.
Don't the 2026 and 2027 CMS prior-authorization rules make this unnecessary?
They help, but they do not replace it. CMS-0057-F requires Medicare Advantage, Medicaid, CHIP, and federal marketplace plans to offer prior-authorization APIs by January 2027, but it does not cover state-regulated commercial or self-funded plans, assemble chart evidence, or work denials.
Why is there no price on this page?
Work under HIPAA is custom-scoped, with the compliance framework governing the architecture, so the published packages and their prices do not apply. The engagement is quoted after scoping.
Is this medical or legal advice?
No. ITECS does not provide medical or legal advice through its agents. The agent is administrative: it compares documentation with published criteria and drafts or flags for review; clinicians and staff decide, and no design promises an outcome.
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