The payer's manual prior-auth review queues averaged 11 days, well outside the 7-day commitment in their provider contracts. Eight percent of denials were being appealed and overturned, eroding revenue and reputation.
Provider abrasion was rising. NPS among in-network providers had dropped 21 points in 18 months, with prior-auth experience cited as the primary reason in exit interviews.
Medical policy was authoritative and dense - over 1,400 pages of guidelines, with monthly updates. No off-the-shelf vendor product had been able to keep pace.
Built a clinical-evidence retrieval and review platform tuned to the payer's medical policy. The model recommended approve, deny or pend - it never decided. Reviewers approved with one click, or edited with context.
For deny cases where the system identified a likely deficiency, the platform drafted an appeal letter against the provider deficiency, with explicit citation to the clinical guideline. This shifted provider experience from punitive to informative.
Live policy ingestion: when medical policy updated, the system re-indexed within 30 minutes. Reviewers always saw the latest guideline, with diff highlighted.
Deployed under a fully BAA-covered Azure tenancy with no PHI leaving the payer's environment. SOC 2 Type II and HITRUST controls were inherited from the existing platform.
Provider relations stopped describing prior-auth as a complaint topic and started describing it as a satisfaction driver. We measured that shift quarter-on-quarter for four quarters.