Prior authorization at machine speed: an agent reference architecture for payers

Prior authorization creates administrative work for payers and providers and can delay care. A useful workflow must preserve clinical review while improving how evidence is gathered.

Why it's hard for traditional automation

Reference architecture

1. 1.Intake agent.
2. 2.Clinical evidence agent.
3. 3.Policy reasoning agent.

Governance is the deal-breaker

No payer ships PA automation without four guardrails: full audit trail of every prompt and citation, clinician sign-off on the decision policy, regulator-ready model cards, and an appeals-friendly rationale on every decision.

Outcomes you can underwrite

• Straight-through processing rate on eligible cases.
• Median turnaround time for eligible cases.
• PA-related call volume and escalation rate.