Every prior auth delayed
is a patient waiting.
The CAIBots Healthcare execution stack executes directly inside Epic, Cerner, and payer systems — prior authorization, claims adjudication, clinical trial matching, and adverse event reporting with HIPAA-native governance and physician review gates at every clinically relevant decision point.
What executes in your
healthcare systems.
HIPAA-native execution workflows writing directly into Epic, Cerner, payer portals, and clinical systems — with physician review gates configured at every clinically relevant decision threshold.
PA requests retrieved, eligibility verified against payer criteria, clinical necessity assessed against treatment protocols, and decisions executed directly into the EMR and payer portal — with automatic physician escalation for edge cases requiring clinical judgment.
Claims received, ICD-10/CPT coding validated, payer adjudication rules applied, and payment routing executed — with automatic denial management workflow triggered for any rejection, including root cause analysis and appeal brief generation.
New patient referrals matched against active trial criteria in real time — biomarker profiling, eligibility scoring, contraindication flagging, and enrollment pre-initiation executed directly into the EMR and trial management system.
Adverse event signals detected in EHR, lab, and medication records — classified for severity, assessed for reportability under FDA MedWatch criteria, and submitted with auto-generated case reports within the 15-day regulatory window.
30-day deployment
entry points.
Highest-value healthcare workflows to automate first — immediate clinical and financial impact with zero disruption to existing care workflows.
Start with your highest-volume, highest-friction PA workflows — typically oncology, specialty pharmacy, or advanced imaging. Immediate reduction in administrative burden with same-day approval rates replacing 5-day manual average.
Automate the ICD-10/CPT coding review queue before submission — identifying undercoding, unbundling risk, and documentation gaps. Measurable reduction in denial rate within the first billing cycle with zero change to clinical workflow.
Automate intake data collection, eligibility verification, and clinical triage classification. Patients routed to the right care setting automatically, with full HIPAA-compliant records created in Epic or Cerner before first clinical contact.
Pre-built healthcare
execution agents.
Every agent is production-ready. Configures to your Epic, Cerner, payer, and clinical trial systems in under 90 days. Physician review gates are mandatory — never configurable out of clinical decision workflows.
Healthcare compliance
at the architecture layer.
HIPAA is not a documentation exercise at CAIBots. PHI governance, physician review gates, and FDA regulatory compliance are enforced at the architecture layer — not configured after deployment and not overrideable by workflow configuration.
PHI access governed by RBAC at the Governance Layer — minimum necessary rule enforced at every data retrieval. Full BAA support for Business Associate compliance. All PHI access logged with access purpose, actor identity, and timestamp on every interaction.
Audit trail requirements for electronic clinical records met at the Execution Layer — every write includes timestamp, actor, input context, and output state. Electronic signature workflows for clinical trial records comply with Part 11 authentication and authorization requirements.
Native FHIR R4 API integration for EHR data exchange — Epic, Cerner, and all major EMR systems accessed via standardized FHIR resources. Clinical data retrieved and written in FHIR-compliant format, enabling seamless interoperability without proprietary transformation layers.
Breach notification workflows automated — any unauthorized PHI access triggers immediate notification protocols, incident documentation, and risk assessment. HITECH-compliant breach response executed and logged within the 60-day notification window automatically.
Prior authorization, claims adjudication, and quality reporting executed against CMS coverage determination criteria and NCD/LCD policies. CMS interoperability rule compliance for payer data exchange automated via standardized API workflows.
For European patient data and life sciences research — data residency enforced, right-to-erasure workflow automated, explicit consent verification at intake. EU patient data never leaves European infrastructure boundaries in on-premise deployments.
Physician review gates —
enforced, never optional.
CAIBots never makes clinical decisions autonomously. Every workflow with clinical impact has a defined governance posture. Physician gates are mandatory, not configurable out, and generate an immutable sign-off record with FDA 21 CFR Part 11 compliance.
| Workflow | Trigger | Governance | Auth Required | Reg Reference |
|---|---|---|---|---|
| PA — Standard Approval | PA request within coverage criteria | Auto-Approve | None | CMS Interop Rule · HIPAA |
| PA — Clinical Edge Case | Complex presentation · documentation gap | Physician Gate | Treating Physician required | HIPAA · FDA · CMS |
| Claims — Clean Submission | Validated codes · payer criteria met | Auto-Process | None | ICD-10 · CMS NCD/LCD |
| Claims — Denial Management | Rejection · denial code detected | HITL Gate | Revenue Cycle Manager | CMS · Payer Contract |
| Trial Match — Candidate | Eligible biomarker match found | Physician Gate | Oncologist / MD sign-off | FDA 21 CFR Part 11 |
| Adverse Event — Expedited Report | Serious unexpected safety signal | Auto-Report + PI | PI notification required | FDA MedWatch · FAERS |
The teams managing
clinical and administrative AI.
See execution in your
healthcare systems.
30-minute session. We map your highest-value healthcare workflows, demonstrate a live PA or claims execution, and scope a 90-day path to production with full HIPAA compliance documentation.