Prior authorization simulator

Run a sample care request through a payer app. VeriProof checks the decision against the health plan’s rules.

How the simulation works

The website proposes approval. VeriProof checks the rules.

  1. The website simulates the agent

    Every prepared scenario starts with the website acting as an AI agent and proposing approval.

  2. VeriProof enforces the business rules

    VeriProof checks the proposed approval against the rules prepared for this demo.

  3. The website applies the result

    VeriProof returns one of five outcomes: Allow, Warn, Transform, Escalate, or Deny. The website applies that outcome to the simulated action.

In a real integration, your application applies VeriProof's result before the proposed action proceeds.

  1. Choose what the agent approvesEvery prepared scenario starts with simulated agent approval
  2. See VeriProof's decisionPass, escalate, or stop based on the business rules

Choose a scenario

The prior authorization

Each sample request ends differently. Pick one, or change the review facts below.

Sample member
Sam Rivera · automated denial
Requested service
Biologic infusion
Request timing
Routine
Medical-necessity score
46 out of 100
Diagnosis criteria are met
Yes
Change scenario details

The payer app proposes to deny this request.

No physician has reviewed this request. VeriProof stops the payer app’s proposed denial.

Records created in this public demo can be seen by other visitors, so use the sample data rather than your own.

Configuration details

How this demo is set up

Review the application settings, rules, and evidence fields used in this simulator.

VeriProof setup

Industry
Healthcare & Life Sciences
Application
Prior Authorization Processor
Environment
Public demo workspace
Rule enforcement
On, rules can stop automated adverse determinations
Rule set
Prior authorization and physician-review guardrails

Related frameworks

Industry context: CMS-0057-F · State utilization-review rules · ERISA claims procedures

The payer app's own checks

The sample app proposes an authorization decision. VeriProof then checks the health plan’s physician-review requirement.

  • Propose denial when conservative-therapy evidence is missing or the score is below 50.
  • Otherwise, propose approval when diagnosis criteria are met and the score is at least 70.
  • Request utilization-management review for all other cases.

The company rules VeriProof enforces

The health plan sets these rules outside the app. A stopped denial waits for physician review; it is not an approval of care.

  • Stop an automated denial that has not been reviewed by a physician.
  • Send an urgent approval with a specialty mismatch to utilization management.
  • Send a borderline approval below 75 to a person before it takes effect.
Review the details saved with each run

The saved record connects the sample request to both decisions. No real member data is used.

member_name / member_id

The sample member reference used to find the authorization record.

requested_service / urgency

The requested care and timing used in the app and rule checks.

diagnosis_criteria_met / conservative_therapy_documented

The clinical and step-therapy evidence reported for this sample request.

ordering_specialty_match / medical_necessity_score

The specialty and model-output facts used by review rules.

physician_review_completed

Whether a physician reviewed an adverse determination before it could take effect.

local_decision / governance_action / final_decision

The payer app decision, rule check, and actual outcome saved as separate facts.