Prior Authorization Automation for a Large Health Insurer
Regional health insurer, Southwest US
01 / Challenge
Manual prior authorization review was taking an average of 4.2 days per case, generating physician abrasion and 1,100 appeal cases per month. The clinical operations team of 28 reviewers was processing 6,000 PA requests monthly with inconsistent approval criteria and no audit trail.
02 / Approach
We deployed an agentic PA review system that extracts clinical criteria from submitted documentation using a HIPAA-compliant private model, cross-references against evidence-based clinical guidelines, and generates a structured recommendation with a full audit trail. Complex cases route to human reviewers with pre-populated decision support.
03 / Outcome
Average PA processing time fell from 4.2 days to 11 hours. First-pass auto-adjudication rate reached 68% of cases. Appeal volume dropped 44% over the first quarter as approval consistency improved. Clinical staff now focus exclusively on the most complex cases requiring clinical judgment.
Representative case study illustrating common agentic-AI deployment patterns in Healthcare; not a specific QuettaMinds client engagement.
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