HIP One Medical Necessity Agent

The same agent and the same evidence-evaluation pipeline serve three points in the payer decision lifecycle:

• Prior Authorization — Pre-service determination of whether requested care meets medical necessity criteria.
• Pre-Payment Medical Review — Post-service, pre-payment confirmation that delivered care met criteria for coverage.
• Post-Payment Audit — Retrospective review of paid claims against medical policy.

Same input, same evaluation, same structured outcomes — only the trigger point in the payer lifecycle differs.

Coverage

Supports Medicare Fee-for-Service, Medicare Advantage, and commercial payers whose medical policies follow Local Coverage Determination (LCD) and National Coverage Determination (NCD) structures.

Architecture

The agent operates as three coordinated services:

• Data Extraction Agent (DEA) — Ingests the request and assembles a structured FHIR bundle of clinical evidence from submitted documentation.
• Evidence Sufficiency Inspector (ESI) — Evaluates whether the bundle contains the data elements required to render a determination against the applicable policy.
• Clinical Quality Intelligence Layer (CQIL) — Runs the criteria evaluation via two specialized sub-agents (Agent A and Agent B) for each supported policy.

Outcomes

Every request resolves to one of three outcomes:

• FULL_APPROVE — Criteria clearly met by the structured evidence. Decision issued.
• NEEDS_HUMAN — Criteria interpretation requires clinical judgment. Case routed to a human clinical reviewer with the evidence bundle.
• INSUFFICIENT — Evidence bundle lacks required data elements. Additional documentation requested.

Human-in-the-Loop

The agent does not issue denials. Every case that is not a clear approval routes to a human clinical reviewer. The agent's role is to expedite the unambiguous cases and to assemble clinical evidence packages for cases requiring human judgment.

Infrastructure and Deployment

• Deployed on Microsoft Azure
• PHI encrypted in transit (TLS 1.3) and at rest (AES-256)
• HIPAA-aligned through Azure's Business Associate Agreement chain
• Tenant isolation through Azure subscription boundaries
• Full audit logging of every determination request and outcome

For customers with elevated compliance requirements, the agent can be deployed inside an existing HITRUST environment or on Azure Government Cloud, inheriting the customer's compliance boundary.

User Roles

• Admin — Manages users, permissions, and agent configuration.
• Clinical Reviewer — Reviews cases routed for human judgment, issues clinical determinations, and provides feedback.
• User — Submits requests and monitors determination outcomes.

About

HIP One is the Reasoning Lobe of the Healthcare Brain — Genzeon Platforms' unified architecture for governed clinical intelligence. The Healthcare Brain spans three platforms: HIP One (clinical reasoning), PES One (member engagement), and CPS One (ethical governance). Built and maintained by Genzeon Platforms. Participant in the CMS WISeR Model.