The UiPath Solution for prior authorization orchestrates intake, validation, clinical review, and determination so utilization management teams review more cases and meet CMS turnaround mandates.
The UiPath solution for prior authorization
The UiPath Solution for prior authorization orchestrates intake, validation, clinical review, and determination so utilization management teams review more cases and meet CMS turnaround mandates.
Prior authorization automation and orchestration transforms utilization management. UiPath orchestrates the full review lifecycle so teams deliver better decisions, faster.
Request intake, clinical review support, and final determination, orchestrated as one case so clinicians focus on judgment calls.
Stage 01
Capture prior authorization requests from fax, portal, EDI/API, and call center. UiPath IXP™ extracts request data and flags missing clinicals. Robots validate eligibility, benefits, and authorization requirements against your policies.
Stage 02
Agentic AI summarizes attached medical records, compares clinical evidence against payer policy, surfaces satisfied and unsatisfied criteria, and recommends a decision with cited evidence for RN and medical director review.
Stage 03
UiPath Maestro™ orchestrates human-in-the-loop review, writes outcomes back to the care management system, and generates approval, denial, or RFI correspondence to providers automatically.
AI summarizes records and recommends decisions with cited clinical evidence.
Intake, validation, clinical review, and correspondence run in one workflow.
Maestro dashboards and audit trails across every reviewer and determination.
Deploys on top of care management, claims systems, and provider portals.
UiPath Maestro orchestrates long-running cases across claims, prior authorization, and care management on one governed platform.
Watch UiPath ingest a prior authorization request, validate eligibility, summarize clinical evidence, and route the case for clinician review in one orchestrated workflow.
WHITE PAPER
A deep look at how payers can transform prior authorization review end to end without replacing core systems.
Common questions about prior authorization automation, how agentic AI fits in, and how the UiPath Platform meets CMS and Medicare prior authorization mandates.
Prior authorization is the process health plans use to confirm that a requested service, procedure, or medication is medically necessary and covered before care is delivered. It protects quality and manages medical spend, but the manual review work behind it is slow, inconsistent, and expensive. Prior authorization automation modernizes that work without changing the underlying clinical or regulatory model.
Prior authorization automation uses software to handle the administrative and clinical work in a prior authorization request: capturing the request across channels, extracting and validating data, checking eligibility and policy rules, summarizing medical records against medical necessity criteria, and routing the case for clinician decision. Modern prior authorization automation combines AI agents, robots, and people on one platform so every step is fast, consistent, and auditable.
Prior authorization AI works on three layers. It extracts structured data from unstructured sources like faxes, portals, and attached medical records. It summarizes a patient’s chart and maps evidence against payer-specific medical policy. And it recommends a decision with cited evidence so nurses and medical directors can approve, deny, or request more information faster and more consistently. The clinician still owns the decision.
CMS requires 72-hour expedited and 7-day standard turnaround for most prior authorization decisions, and the CMS Interoperability and Prior Authorization Final Rule adds requirements for electronic prior authorization and API exchange for Medicare Advantage, Medicaid, and ACA plans. AI prior authorization is the practical path to compliance: UiPath automates the work that drives turnaround, including intake, validation, and clinical review support. Maestro keeps every case on a compliant clock with full audit trail visibility.
Business orchestration coordinates the full prior authorization lifecycle as a single case. Intake, eligibility checks, policy lookups, record summarization, clinician review, and provider correspondence all run on one platform, with state preserved across steps and exceptions handled automatically. Plans using UiPath have reduced prior authorization turnaround by up to 75%.
No. UiPath deploys on top of your existing care management platform, claims system, and provider portals. Robots, AI agents, and orchestration run across those systems; decisions are written back to the care management system of record. This is the fastest path to modernizing utilization management without a platform replacement project.
Every agent recommendation is surfaced to a nurse or medical director in Action Center with cited evidence from the medical record and payer policy. Clinicians confirm, adjust, or override the recommendation before the outcome is logged to the care management system. Automation handles the data work; people make the calls.
