An AI Worker Pattern for Prior-Authorisation Preparation
How to organise clinical and coverage evidence, reduce administrative rework and preserve clinician and payer decision authority.
Intelliger Editorial Team•Jul 05, 2026Prior authorisation creates work on both sides of the process. Clinical teams assemble documentation, operations staff check requirements and reviewers determine whether the request meets the applicable criteria. Delays often come from missing context, incorrect forms or criteria that were not matched to the request.
An AI worker can prepare a complete, traceable case. It should not make a clinical judgement or coverage determination.
Give the worker an administrative mission
A bounded worker can identify the requested service, retrieve the relevant criteria and form, check required documentation, extract supporting facts with source links and prepare unresolved questions.
The clinician remains responsible for clinical statements and care decisions. The authorised payer reviewer retains the coverage decision. Make both boundaries visible in the interface and audit record.
Minimise data access
The worker should access only the records required for the active case and purpose. Use approved interfaces, role-based controls and short-lived credentials. Do not create a broad secondary copy of clinical records for general model access.
Record what was accessed, why it was needed and when the mandate expired. Redact or omit information that is not required for the process.
Match criteria carefully
Coverage criteria vary by plan, service, date and jurisdiction. The worker must confirm the member, plan, requested service and effective criteria before checking completeness. If any identifier is uncertain, stop and route for correction.
Show the exact source and version used. A summary can help navigation, but the reviewer needs access to the controlling text.
Keep evidence and interpretation separate
The case package can list submitted facts and point to the clinical record. It may indicate that a required element appears absent. It should not invent a diagnosis, reinterpret ambiguous notes or convert statistical similarity into clinical evidence.
When records conflict, present the conflict and request clarification. Do not select the most convenient entry.
Test for safe refusal
Include wrong-member records, plan mismatches, outdated criteria, missing notes, ambiguous service codes, urgent cases and instructions embedded in uploaded material. Confirm that the worker routes urgent or out-of-scope cases through the approved path.
Measure correct criterion selection, evidence-link accuracy, missing-item detection, resubmission rate, reviewer corrections, preparation time and privacy incidents. Examine delays by case type to ensure the workflow does not create uneven burden.
Start where the process is stable
Choose one service category with stable documentation rules, representative volume and named clinical and operational owners. Evaluate historical cases, then run in shadow mode. Introduce live preparation only after the worker reliably identifies when it cannot complete the case.
An OATI Mandate can limit access to one case and purpose. An OATI Receipt can record evidence access and the handoff to the authorised reviewer. These controls support accountability, while healthcare organisations remain responsible for privacy, clinical safety and coverage decisions.