Prior authorization automation.
The OneDose Claims & PA Agent handles the prior authorization pipeline. It detects when a medication needs authorization, assembles the payer’s required evidence from the clinical record, submits the request in the payer’s format, and tracks status until a decision lands — escalating denials and appeals to a human with the reasoning attached.
Prior authorization is mostly a documentation and follow-up problem wearing a clinical costume: the evidence usually exists, and the cost is the hours spent assembling it and chasing the answer.
How does the Claims & PA Agent actually work?
What follows is the mechanism — what the agent does, in what order, and where a human stays in the loop.
It knows a PA is needed before the counter does
The trigger fires when the prescription is processed, not when the claim is rejected. Discovering the requirement at the point of collection is what turns a paperwork task into a patient-facing failure.
It assembles the evidence from the record
Diagnosis, prior therapies tried and failed, relevant labs, the clinical rationale — the payer’s criteria decide what is needed, and the agent pulls it from the record rather than asking a human to go and find it.
It submits in the payer’s format
Every payer wants something slightly different. That variation is the entire tax of PA work, and it is exactly the kind of tedious, rule-shaped variation software absorbs well.
It chases the answer
Status is tracked until a decision lands. The chase is unglamorous, it is most of the elapsed time, and nobody misses doing it.
It escalates a denial to a human
A denial is a decision with a reason, and the reason determines whether the answer is an appeal, a different therapy or a conversation with the prescriber. That is a judgement, so it goes to a person — with the denial reason and the assembled evidence attached.
What will the Claims & PA Agent not do?
The limits matter more than the capabilities when the subject is medication, so they are stated plainly rather than left to be discovered in a pilot.
- It does not decide clinical appropriateness. If a payer denies on clinical grounds, that is a prescriber conversation, not an agent one.
- It does not appeal on its own authority. It drafts and escalates; a human decides whether and how to push back.
- It does not fabricate evidence. If the record does not support a criterion, the agent says so rather than filling the gap — which is the only acceptable behaviour when the output is a payer submission.
How does this agent fit with the others?
The Claims & PA Agent is one of six OneDose agents that share one patient context and one audit log. That shared context is the difference between a workforce and six tools: the voice agent already knows what the follow-up agent asked yesterday, so the patient is not asked to repeat themselves and the care team reads one history rather than six.
Frequently asked
- What is prior authorization automation?
- Prior authorization automation is software that detects when a medication requires payer authorization, assembles the required clinical evidence from the patient record, submits the request in the payer’s format, and tracks it to a decision — replacing the manual assembly and chasing that makes PA slow, while leaving clinical judgement and appeal decisions with humans.
- Can the agent appeal a denied prior authorization?
- It drafts and escalates rather than deciding. A denial carries a reason, and the reason determines whether the right answer is an appeal, an alternative therapy, or a conversation with the prescriber — so a human makes that call with the denial reason and the assembled evidence in front of them.
- What if the clinical record does not support the payer’s criteria?
- The agent reports the gap. It does not fill it. The output of this agent is a submission to a payer, which is the last place a plausible-sounding guess belongs.