Every prior auth delayed
is a patient waiting.
Governed, auditable AI agents working directly inside Epic, Cerner, and payer portals — prior authorization same-day instead of 5 days, claims adjudicated with full ICD-10 validation, and adverse events filed within the 15-day FDA window. Physician review gates active at every clinical decision point.
What changes when CAIBots
processes a prior authorization.
A specialty pharmacy PA request — before and after. Same payer criteria. Same clinical necessity standards. Different execution model. A patient waiting either way.
Same-day decisions.
Physician gates never bypassed.
Prior authorization is where the largest clinical and financial impact exists for health systems and payers. CAIBots automates the full intake-to-decision cycle — coordinators handle complex cases requiring clinical judgment, not data gathering.
PA requests retrieved, eligibility verified against payer criteria, clinical necessity scored, and same-day decisions executed directly into Epic or Cerner and the payer portal. Mandatory physician review gate enforced on any case exceeding clinical complexity threshold.
Claims received, ICD-10/CPT coding validated, payer adjudication rules applied, and payment routing executed — with automatic denial management and appeal brief generation including root cause analysis on any rejection.
New referrals matched against active trial criteria in real time — biomarker profiling, eligibility scoring, contraindication flagging, and pre-enrollment initiation executed into the EMR and trial management system. Physician sign-off gate enforced before any enrollment step.
Adverse event signals detected across EHR, lab, and medication records — classified for severity, assessed for FDA MedWatch reportability, and submitted with auto-generated case narratives within the 15-day regulatory window.
Watch a PA approve same-day.
See a trial match in minutes.
Production-accurate scenarios. Live Epic and payer portal writes. Real HIPAA audit trails. Physician gates visible at every clinical decision step.
30-day deployment
entry points.
Prior authorization first — where the largest clinical and financial impact exists. Claims coding and trial matching follow with clear expansion paths.
Start with your highest-volume, highest-friction PA workflow — typically oncology, specialty pharmacy, or advanced imaging. Same-day approval rates replace 3–5 day manual average. Immediate reduction in coordinator administrative burden and provider escalations.
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 disruption to existing clinical workflow.
Automate intake data collection, eligibility verification, and clinical triage classification. Patients routed to the correct care setting automatically, with full HIPAA-compliant records created in Epic or Cerner before first clinical contact.
Pre-built healthcare
execution agents.
Every agent production-ready. Configures to Epic, Cerner, payer portals, and clinical trial systems in under 90 days. Physician review gates are mandatory at every clinical decision threshold — never configurable out.
HIPAA 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 settings.
PHI access governed by RBAC at the Governance Layer — minimum necessary rule enforced at every data retrieval. Full BAA support. 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 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, no 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 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.
European patient 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 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 | Serious unexpected safety signal | Auto-Report + PI | PI notification required | FDA MedWatch · FAERS |
The teams managing
clinical and administrative AI.
Watch a PA approve
the same day it's submitted.
30-minute session. We map your highest-volume PA or claims workflow, demonstrate a live HIPAA-compliant execution, and scope a 90-day path to production with full physician gate documentation.