Yes, AI can do prior authorization, for the repetitive parts of it, while a clinician keeps the medical judgment. An AI agent can check whether a service needs authorization, gather the CPT code, the ordering diagnosis, and the supporting clinical notes, and submit the request on the channel the payer accepts: a 278 EDI transaction where the payer supports it, or a payer portal where it does not. It then tracks the request to an approval, a denial with a stated reason, or a request for more information, and writes the authorization number and status back into the EHR, whether that is Epic, eClinicalWorks, or another system. It operates under HIPAA safeguards on protected health information. What AI does not do is decide medical necessity, override a payer's clinical criteria, or argue an appeal.
Can AI do prior authorization?
Yes, AI can do prior authorization for the mechanical work that surrounds the clinical decision. The prior authorization workflow runs in a set order: confirm the member's eligibility and whether the service needs review, gather the service code, diagnosis, and clinical documentation, submit the request, and track it to a decision. AI can carry every one of those steps except the clinical judgment at the center. The reason this matters is the sheer volume: the American Medical Association reports that physicians complete about 39 prior authorizations per physician per week, taking roughly 13 hours of practice time, per the AMA. Taking the submission and follow-up off a person's plate is where the time goes back. We cover the full picture on our prior authorization automation page, including which parts stay with the clinician.
How does AI submit a prior authorization?
AI submits a prior authorization by assembling the request and sending it on the channel the payer accepts. It gathers the CPT service code, the ordering diagnosis, and the supporting clinical notes, then routes them either through a 278 (Health Care Services Review) EDI transaction, where the payer supports electronic authorization, or through a browser agent that operates the payer portal, where the payer does not. The agent submits the request, then tracks it to one of three outcomes: an approval, a denial with a stated reason, or a request for more information. When more information is needed, the agent surfaces exactly what is missing so a person can supply it, rather than letting the request stall unnoticed. Finally it writes the authorization number and current status back to the EHR, so scheduling and billing see the result in one place instead of chasing a portal.
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Book an auditCan AI do prior authorization in Epic?
Yes, AI can do prior authorization inside Epic, and the point of doing it there is that the authorization lands on the order the care team already sees. An agent reads the ordered service from Epic, confirms whether that service needs authorization for the member's plan, and submits the request through the payer portal or a 278 transaction. It then posts the authorization number, the status, and any denial reason back to the Epic order and referral records. The agent operates within the practice's existing Epic access and permissions rather than a separate system, and every submission and status check it performs is logged, so a person can review what was sent, what came back, and when. Our AI for Epic page describes how voice and browser agents run inside Epic across eligibility, authorization, and follow-up.
Can AI do prior authorization in eClinicalWorks?
Yes, AI can do prior authorization inside eClinicalWorks. An agent pulls the ordered service and the diagnosis from eCW, submits the authorization request through the payer's portal, and, when a request is pending, holds on the payer's phone queue to check or expedite it. It writes the authorization number and status back onto the eClinicalWorks record so the front desk and billing see the result where they already work, not in a side tool. Because eCW is common in ambulatory and community health settings that carry high authorization volume, moving the submission and the phone hold to an agent frees staff for the cases that actually need a person. Our AI for eClinicalWorks page covers how agents operate inside eCW workflows in more detail.
What prior authorizations still need a human?
The prior authorizations that still need a human are the ones that turn on clinical judgment. A peer-to-peer review, where a physician discusses the case directly with the payer's reviewer, is a clinical conversation and stays with the clinician. An appeal that argues medical necessity is a clinical argument, not a form to fill. A request where the documentation does not yet support the service needs a clinician to decide what is appropriate, not an agent to force it through. And a novel case that falls outside the payer's standard criteria needs human review on both sides. AI handles the submission, the portal navigation, the phone hold, and the status tracking, and it hands the case to a person the moment a real medical decision is required, with the context already assembled. That division, machine on the repetitive work and clinician on the judgment, is how the workload comes down without ceding the decisions that should stay with people. To map what AI can take off your prior authorization queue, book a call with Flexbone.