Healthcare Prior Authorization & Denial Management AI Agent

Denial management is a primary pain point in healthcare due to fragmented data across provider EHRs and payer adjudication systems. This multi-agent AI tool bridges that gap, shifting your organization from reactive billing to proactive authorization.

## How It Works

The solution deploys a coordinated team of specialized AI agents:

**Intake Agent**

• Scans clinical notes and structured intake forms
• Extracts necessary procedure and diagnosis codes automatically
• Identifies missing information before submission

**Clinical Evidence Agent**

• Connects to your EHR to pull relevant lab results, images, and prior clinical history
• Builds a comprehensive case for medical necessity
• Consolidates fragmented clinical data into a unified evidence package

**Compliance Agent**

• References up-to-date payer-specific clinical policies stored in Amazon Bedrock Knowledge Bases
• Ensures each request meets coverage criteria before submission
• Validates compliance against the latest policy updates

## Key Outcomes

• **Reduced Denial Rates:** Proactively corrects missing information before submission, preventing denials at the source
• **Complete Audit Trail:** Every decision is documented with full traceability for compliance and appeals
• **Proactive Authorization:** Shifts workflow from reactive billing corrections to proactive, policy-compliant submissions
• **Bridged Data Gaps:** Connects provider EHR data with payer adjudication requirements seamlessly

## Security and Compliance

This solution is deployed on AWS infrastructure and leverages AWS security capabilities including encryption in transit and at rest. Data flows between the container-based UI, AWS Lambda functions, and Amazon Bedrock Knowledge Bases are secured using AWS-native controls. Organizations handling PHI should review their own compliance requirements and coordinate BAA coverage with AWS as needed.

## AWS Architecture and Integration

This solution is purpose-built on AWS services for reliability, scalability, and security:

• **Amazon Bedrock AgentCore and Agent Gateway:** Core deployment platform for the agentic AI team
• **Amazon Bedrock Knowledge Bases:** Stores and retrieves payer-specific clinical policies for real-time compliance checking
• **AWS Lambda and Amazon API Gateway:** Powers backend services with serverless scalability
• **Container-based UI:** React UI and Crew AI deployed as a container for flexible access
• **AWS CloudFormation:** Templates provided for streamlined deployment of AgentCore resources

Customers select their own LLM model and pay for usage based on their selection, giving full control over model choice and associated costs.

## Prerequisites and Limitations

• Requires EHR API access for the Clinical Evidence Agent to retrieve patient data
• Payer-specific clinical policies must be ingested into Amazon Bedrock Knowledge Bases in supported formats
• Deployment requires an active AWS account with access to Amazon Bedrock, Lambda, and API Gateway
• Customers are responsible for ensuring their AWS environment meets applicable regulatory requirements

## Getting Started

To evaluate this solution for your organization, request a guided demo or discovery call through the support contact provided on this listing. Integrationpath LLC offers professional services for onboarding and integration assistance to help you connect your EHR systems and configure payer policy databases.

## Who This Is For

This tool is designed for healthcare providers, revenue cycle management teams, and payer organizations looking to reduce claim denials, accelerate prior authorization workflows, and maintain strict compliance with payer-specific clinical policies. It is ideal for organizations dealing with high denial volumes and fragmented clinical data across multiple systems.