Who reviews a proposed denial, and does the physician see what the agent saw?
Health plans and prior authorization
Let the prior authorization agent approve the well-documented requests
Clear requests move without waiting in a queue. A proposed denial stops until a physician reviews it, and a mismatch goes to utilization management with the clinical facts attached.
Connecting the agent? See the developer guide for Healthcare & Life Sciences
What stands between the agent and your members
Health plans want faster decisions. Clinical and compliance teams need to know the agent cannot deny care on its own.
Under CMS-0057-F, affected payers give a specific reason when they deny a non-drug request. That reason should stay with the decision.
State utilization-review rules differ, so the physician-review rule has to change without a code release.
Built-in handoff
Every proposed denial reaches a physician
Physician reviewer
The denial waits in the physician’s Inbox, or arrives by email, with the clinical facts. Reminders go out, overdue reviews escalate, and the decision returns to the agent.
See the six role portals and how work moves between themA denial the agent was not allowed to make
The simulator’s first request, as your plan would handle it.
Medical director
Sets the rule: no automated denial goes out until a physician has reviewed it.
Physician reviewer
Gets the request in the Inbox with the criteria, the missing therapy evidence, and the proposed denial, and makes the call.
Utilization management lead
Sees how many requests cleared without a person and how long physician reviews are taking.
Compliance
Pulls a quarter of denials, each with its reviewer and reason, when a state regulator asks.
Prior authorization and the work around it
Start with prior authorization, then add the neighboring decisions that share the same reviewers.
Prior authorization decisions
The agent proposes approve or deny. Plan rules decide whether an approval proceeds, and a physician sees every denial.
Urgent and expedited requests
Urgent requests with a mismatch go to utilization management first, so review time goes to the decision, not the search for the file.
Appeals intake
When a member appeals, the reviewer starts from the original decision, its criteria, and who reviewed it.
Member data stays where it belongs
References, not records
Record member and service references instead of copying clinical notes. Access follows each person’s role.
No patient data on a public chain
In the managed service, each record’s fingerprint goes to Azure SQL Database Ledger by default. If you choose Solana instead, it never receives personal or patient data.
Your HIPAA program
Access controls and decision records support the safeguards your HIPAA program already defines.
See how your physician-review rule would work
Run the prior authorization simulator, then open the portal as the business owner and as the compliance officer.