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 are 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 are 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. Pharmacovigilance compliance executed, not documented.
30-day deployment
entry points.
Highest-value healthcare workflows to automate first — immediate, measurable 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 automatically. Measurable reduction in denial rate within the first billing cycle.
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.
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.
PHI access governed by RBAC at the Governance Layer — no execution touches PHI without role-based authorization. Minimum necessary rule enforced at every data retrieval. Full BAA support for Business Associate compliance. All PHI access logged with access purpose and actor identity.
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.
The teams managing
clinical and administrative AI.
Prior auth completed in minutes.
Not days. Not phone calls.
Real healthcare execution scenarios with HIPAA governance, Epic/Cerner integration, and mandatory HITL gates for high-risk clinical decisions.
| Workflow | Auto Execute | HITL Gate | Reg Reference |
|---|---|---|---|
| Prior Auth — Standard | Auto-Routes | None | HIPAA · CMS |
| Prior Auth — High Risk Dx | Drafts Request | Physician Review | HIPAA · CMS |
| Claims Adjudication — Clean | Auto-Adjudicates | None | ICD-10 · CMS |
| Adverse Event Detection | Flags + Drafts | Clinical Review | FDA MedWatch |
| Clinical Trial Matching | Identifies Matches | PI Authorization | FDA 21 CFR · FHIR |
| EMR Record Update | Writes to EMR | Post-Write Validation | HIPAA · HL7 FHIR |
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.