AI Prior Authorization for Payers
These are prior authorization platforms for health plans and other entities that do utilization management. They use AI to automate UM decisions and improve efficiency of UM nurses / clinicians. Functions usually include:
Ingestion of clinical policies and translation into decision trees
Automatic population of prior auth decisions for approval
Automatic approval of auths that meet certain criteria
Documentation of decision reasons, i.e. traceable decisions
Prior authorization vendors vary meaningfully in their service coverage, with some specialized for pharmacy and others focused on certain types of medical services.
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Autonomize AI
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Autonomize AI Prior Auth Copilot
Company Info
Founded: 2022
Headcount: 11-50
Customers
Customers Served: Digital Health Provider, Hospital / Health System, Ambulatory Practice
Product Overview
Security and Compliance Certifications: SOC 2 Type 2, HIPAA
AutonomizeAI's Prior Auth Copilot extracts and summarizes member authorization requests, links clinical data to internal sources, and assesses compliance with clinical guidelines. It generates decision summaries that help reduce administrative burdens and speed up approvals.
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Banjo Health
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Banjo Health
Company Info
Founded: 2019
Headcount: 11-50
Customers
Verified Customers: 4
Customers Served: Health Plan, Pharmacy Benefit Managers
Product Overview
Security and Compliance Certifications: HITRUST CSF, HIPAA
Banjo Health streamlines the prior authorization process for health plans and pharmacy benefit managers. BanjoPA is their prior authorization platform for health plans that consolidates prior authorization requests, provides decision recommendation based on predefined clinical decisions trees, and creates documentation to support appeal processes. Banjo Composer takes clinical criteria as inputs and creates clinical decision trees by automatically identifying decisions points and delivering in a platform that supports editing and testing.
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Anterior
Anterior
Company Info
Founded: 2022
Headcount: 51-200
Customers
Customers Served: Health Plan
Product Overview
Security and Compliance Certifications: HITRUST CSF, HIPAA
Anterior is a generative AI platform for payer organizations, providing a co-pilot dashboard to empower UM nurses to get all of the right data summarized and presented so they can make the right decision faster.
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Basys.ai
Basys.ai
Company Info
Founded: 2021
Headcount: 1-10
Customers
Verified Customers: 1
Customers Served: Health Plan
Product Overview
Security and Compliance Certifications: HIPAA
Basys.ai
is an AI-powered platform that streamlines prior authorization (PA) for health plans using GenAI for policy encoding and request processing. It enables rapid payer onboarding and policy updates, automates complex policy rules and decision logic, and allows UM nurses to verify recommendations while making decisions. The platform recommends alternative care pathways when requests don’t match existing policies and records overrides for analytics and model improvement. It features a portal for direct document submission, API integration with Epic, and OCR for handling document types like fax.
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Cohere Health
Cohere Health
Company Info
Founded: 2019
Headcount: 501-1000
Customers
Verified Customers: 2
Customers Served: Health Plan
Product Overview
Security and Compliance Certifications: HITRUST CSF, HIPAA
Cohere Health automates and optimizes the prior authorization process for health plans by integrating with EHR systems, digitizing authorization requests, and applying AI and clinical intelligence to automate decisions and improve efficiency. The platform supports real-time analytics and interoperability, facilitating faster patient care and reducing administrative costs.
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GenHealth.ai
GenHealth.ai Auto Prior Auth
Company Info
Founded: 2023
Headcount: 1-10
Customers
Customers Served: Health Plan
Product Overview
Security and Compliance Certifications: SOC 2 Type 2, SOC 2 Type 1, HIPAA
GenHealth.ai
's Auto Prior Auth system automates the prior authorization process for healthcare providers and insurers with auditable, explainable decisions. It uses AI to extract patient data from various sources, including faxes, HL7v2, and call center transcripts. The system ingests medical policies and generates decision recommendations based on plan-specific workflows. It provides early abuse detection, individual risk assessments, and provider gold card recommendations.