Add custom payor rules for drugs or procedures
Supporting both traditional and modern workflows
Complete visibility into every decision and action
A prior auth engine built for payors that strengthens clinical consistency, accelerates reviews, and delivers determinations using your own guidelines and formulary rules.
Turn incoming PA requests into structured, review-ready cases.
Automatically ingest prior authorization requests from faxes, forms, and electronic submissions, normalize the data, and update records directly within your existing UM system—automating triage, case creation, and routing from the start. Checks for duplicate prior auths, auth history, and medical charts to prevent redundant work and ensure accurate processing.
Learn moreEvaluate each request against the right coverage criteria.
Evaluates each prior authorization directly against your criteria and requirement logic, including gold carding, prior therapy rules, and quantity or safety limits, with explainable audit trail for payer clinicians. Integrated with CMS NCD/LCD, medicaid state policies, homebuilt guidelines, NCCN, and more to ensure every policy check is done accurately with the correct policy.
Learn moreAI voice agent that calls providers for missing clinical documentation.
Case Health AI’s Provider Outreach module uses AI voice agents to contact provider offices and request missing clinical documentation for medical necessity review. It explains what’s needed, follows up automatically, and keeps prior authorizations moving without manual phone tag. Each outreach attempt is logged with summaries, timestamps, and requested items for a clear audit trail. Health plans can configure triggers, documentation requests, and escalation rules.
Learn more about Provider OutreachStart with prior auth and expand across operations. Enable or pause any agent instantly — each runs within the guardrails and policies you configure.
Ingests requests from fax, portal, phone, and X12 278 and opens a clean, structured case.
Runs medical necessity review against policy criteria and cites every conclusion with source links.
Produces a one-page clinical summary of each case for fast reviewer sign-off.
Verifies new prior auth case is not a duplicate of an existing case.
Closes missing-information gaps with providers via call, fax, and portal outreach.
Verifies licensure and credentialing status and keeps provider records current.
Reviews appeals for medical necessity review and provides recommendations.
Reviews medical chart to determine if the patient should be put on a care plan.
Case Studies
A regional plan deployed Case Health AI across prior authorization workflows and watched manual work drop while membership grew. No new hires needed.
Case Health AI automates high-volume prior authorization workflows, eliminating repetitive manual tasks and freeing clinical teams to focus on complex cases.
Process significantly more authorizations in the same period. Plans reduced daily PA volume by 50% while handling more cases than ever before.
Regional Florida Health Plan
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Members
Members and providers receive faster status updates and clearer communications, reducing friction and improving satisfaction across the care journey.
Automating payer operations delivers measurable returns. Plans using Case Health AI have seen 3x ROI with lower operational overhead.
Care Management
Case Health AI's voice agent calls members and holds a natural, guided conversation — assessing needs, closing gaps, and capturing structured documentation as it goes. Your care managers arrive to a completed call summary instead of a blank form, so they spend their time on care, not prep.
Captured This Call
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Security & Compliance
Case Health AI is designed from the ground up for the security and compliance requirements of health plans. Every workflow is HIPAA-compliant, auditable, and protected by enterprise-grade controls.
All PHI is handled with end-to-end encryption, strict access controls, and full audit logging. Every workflow is designed to meet HIPAA requirements by default.
Independently audited against SOC 2 Type II criteria for security, availability, and confidentiality across our platform and infrastructure.
HITRUST certification validates that our controls meet the rigorous standards required for healthcare data management and regulatory compliance.
Every AI output is bounded by configurable clinical and operational rules, with human review controls and full auditability built into every step.
Built for enterprises—handle millions of requests with zero downtime.
