Live Agent Demo

Prior Authorization Automation

Watch an autonomous agent review PA requests against InterQual clinical criteria, approve or deny in seconds, prep peer-to-peer escalation briefs, and generate a complete audit trail — without a single human touch.

Agentic AI InterQual Criteria Simulated
Domain: Utilization Management · Prior Authorization
Steps: 6 Runtime: <90 sec AI Type: Agentic + GenAI
PA Request Queue Ingested
Scanning
Payer SilverCare MA (HMO)
Batch Date 2025-03-14
Requests 6 pending
STAT 1
agent > ingest_pa_queue(payer="SilverCare MA", batch_date="2025-03-14", count=6)
Request ID Member Procedure CPT Requested By Submitted Priority
PA-2025-0441 Rivera, D. Lumbar Spinal Fusion 22633 Summit Health Partners Mar 12 STAT
PA-2025-0442 Chen, M. Knee Arthroscopy 29881 Northside Orthopedics Mar 12 Routine
PA-2025-0443 Patel, S. MRI Brain w/ Contrast 70553 Riverside Neurology Mar 13 Routine
PA-2025-0444 Thompson, K. Total Hip Replacement 27130 BluePeak Orthopedics Mar 13 Urgent
PA-2025-0445 Williams, R. Spinal Cord Stimulator 63685 PainFree Specialists Mar 13 Routine
PA-2025-0446 Garcia, L. CPAP Device A7034 Sleep Care Associates Mar 14 Routine
6 pending
1 STAT
2 Urgent
12 avg. days to decision (manual)
6 PA requests ingested. Cross-referencing member eligibility, benefit coverage, and prior service history. Prioritizing PA-2025-0441 (STAT)…
InterQual Criteria Assessment
Evaluating
agent > evaluate_criteria(pa_id="PA-2025-0441", guidelines="InterQual-MSK-2025", member_id="MA-00441")
Request PA-2025-0441
Member Rivera, D. (MA-00441)
Procedure Lumbar Spinal Fusion — CPT 22633
Priority STAT
InterQual Criteria Assessment — CPT 22633
✓
Conservative therapy ≥ 6 weeks
Documented PT ×8 weeks, chiropractic ×12 sessions
PASS
✓
Imaging confirms pathology
MRI 2025-02-18: L4-L5 disc herniation, Grade III
PASS
✓
Neurological deficit documented
Radiculopathy, foot drop noted in clinical exam
PASS
✓
Failed epidural steroid injections
ESI ×3, inadequate relief documented
PASS
✓
Functional impairment score ≥ 40
ODI score: 52/100
PASS
⚠
Pre-op medical clearance
Cardiology consult not yet received
PENDING
5/6 criteria met — Conditional Approval pending cardiology clearance
5 of 6 criteria satisfied. Cardiology clearance outstanding — issuing conditional approval with 7-day window for clearance submission…
Decision & Notification
Deciding
agent > issue_decisions(batch="PA-2025-0314", decisions=["approve","conditional","p2p","approve"])
PA-2025-0441 Rivera, D. · CPT 22633 · Lumbar Spinal Fusion
Conditional Approval
Approved pending cardiology clearance by Mar 21, 2025. 5 of 6 InterQual criteria met. Conditional approval letter drafted — CMS MA regulation compliant.
PA-2025-0442 Chen, M. · CPT 29881 · Knee Arthroscopy
Approved
All criteria met. Approved 10 units / 1 facility visit. Authorization effective immediately.
PA-2025-0446 Garcia, L. · CPT A7034 · CPAP Device
Approved
CPAP criteria met — AHI >15 documented in sleep study. Approved 1 unit. Member notification sent.
PA-2025-0445 Williams, R. · CPT 63685 · Spinal Cord Stimulator
Peer-to-Peer Required
SCS criteria partially met. Clinical peer review requested — auto-drafted P2P brief attached. Expected turnaround: same day.
Approved: 2
Conditional: 1
P2P Required: 1
Pending: 2
Decisions generated for 4 of 6 requests. Williams SCS request forwarded to clinical peer review queue with auto-drafted P2P brief…
Peer-to-Peer Escalation Brief
Generating
agent > generate_p2p_brief(pa_id="PA-2025-0445", lcd="L38076", member_id="MA-00445")
Peer-to-Peer Escalation Brief — PA-2025-0445
Auto-generated clinical summary for peer review
Patient: Williams, R.  |  DOB: 1962-07-14  |  Member: MA-00445
Diagnosis: Chronic intractable back pain (M54.5), Failed Back Surgery Syndrome (M96.1)
Requested: Spinal Cord Stimulator implant (CPT 63685)
Mr. Williams is a 62-year-old male with a 3-year history of chronic intractable lower back pain following two lumbar laminectomies and one revision fusion surgery. Despite aggressive multimodal pain management including long-acting opioids, nerve blocks, and physical therapy, functional impairment remains severe with an Oswestry Disability Index score of 64/100. The requesting provider, PainFree Specialists, recommends SCS implantation as the next clinically appropriate intervention given exhaustion of conservative measures and documented Failed Back Surgery Syndrome.
Supporting Evidence
  • Failed opioid therapy ×24 months (documented taper attempts, inadequate relief)
  • 3 prior spine surgeries: L4-L5 laminectomy (2022), L5-S1 laminectomy (2023), L4-S1 revision fusion (2024)
  • VAS pain score: 8/10 sustained across last 6 assessments
  • Psychology clearance obtained — Dr. Hernandez, March 3, 2025
Recommendation
Approve — meets criteria under CMS LCD L38076 for spinal cord stimulation in patients with Failed Back Surgery Syndrome and documented conservative therapy failure.
Auto-generated by NestedLoop PA Agent  |  Reviewed for clinical accuracy  |  Mar 14, 2025
Brief drafted. CMS LCD L38076 cited. Document flagged for attending physician signature before submission…
Denial & Appeals Preparation
Processing
agent > process_denial(pa_id="PA-2025-0444", denial_code="D-047", generate_noa=true, stage_appeal=true)
PA-2025-0444 Thompson, K. · CPT 27130 · Total Hip Replacement
Denied
Request: PA-2025-0444  |  Member: Thompson, K.  |  CPT 27130
Denial Reason: Conservative therapy not documented (no PT records in file)
Denial Code: D-047
Regulatory Basis: InterQual MSK 2025 — Hip Arthroplasty
Appeal Deadline: May 14, 2025 (60 days)
Notice of Action (NOA) — Preview:
Dear Thompson, K.,
We are writing to inform you that your request for prior authorization for Total Hip Replacement (CPT 27130) has been denied. The clinical documentation submitted does not include evidence of conservative therapy (physical therapy) as required by InterQual Musculoskeletal criteria for hip arthroplasty…
[Full letter — 2 pages, CMS-compliant template]
NOA letter generated Appeal packet pre-staged Provider notified via portal
Auto-Reconsideration Logic
If PT records are submitted within 14 days, expedited reconsideration will auto-trigger. The agent will re-evaluate criteria without manual resubmission. Appeal packet includes a documentation checklist sent to BluePeak Orthopedics.
AI decision — human override available
Human Override — PA-2025-0444 Thompson, K. · CPT 27130
Select Decision
Approve
Conditional Approve
Escalate to P2P Review
Keep Denied
Override Reasoning
Agent re-evaluating with human override…
Override will be logged in the audit trail with your identity and timestamp.
✎ Human Override Applied Decision changed to —
Thompson PA denied — PT documentation not present. NOA auto-generated per CMS regulatory template. Appeal packet pre-staged with documentation checklist…
Audit Trail & Metrics Summary
Complete ✓
PA Batch Complete

6 PA requests processed — 3 approved, 1 conditional, 1 escalated to peer review, 1 denied with NOA. Average decision time: 4.2 seconds per request.

6 Requests Processed
4.2 sec Avg Decision Time
3 Approvals
1 Conditional
1 P2P Escalated
1 Denied
14.8 hrs
Clinical reviewer time saved
100%
CMS audit-ready compliance
Audit Log
Timestamp Action PA ID Outcome Reviewer
14:02:33 Criteria eval PA-2025-0441 Conditional Approval AI Agent
14:02:34 Auto-approve PA-2025-0442 Approved AI Agent
14:02:35 P2P Brief Gen PA-2025-0445 Escalated AI Agent
14:02:36 Denial + NOA PA-2025-0444 Denied AI Agent
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Disclaimer: This is an interactive demonstration using simulated data and pre-scripted AI responses. No real patient, member, or provider data is used. All values are fictional and for illustrative purposes only. Real deployments include full HIPAA compliance, SOC 2 audit controls, CMS regulatory adherence, and clinical peer review oversight.

Proprietary assets of NestedLoop LLC. Reproduction or re-use with explicit consent and authorization from NestedLoop LLC only.