Prior Authorization Automation Complete submissions against the payer's criteria, fewer denials
Prior authorizations are detected, documented and submitted the day the order is placed, and denials get a drafted appeal.
- Installed for you · one-time$249
- Custom build · this process$8,000–15,000 one-time
- Starts whenEHR order event / daily order scan
The subscription suits practices with EHR API access and up to 300 auths a month; most deployments are custom because of EHR integration and BAA requirements. Custom builds start at $2,000 site-wide; this band is for this process and its integrations.
Prior Authorization Automation is an automation Agentmelt installs in EHR (Epic, athenahealth, eClinicalWorks…). The free template is a file you import yourself; the kit ($49) adds the setup guide and prompts. Installed for you costs $249 one-time and is live within two working days of access, with a recorded walkthrough and 30 days of fixes. A custom build of this process is $8,000–15,000 one-time; custom builds start at $2,000 site-wide. No call is needed for any option. Written by Max Zeshut; last revised 2026-09-21.
Reference stack: Claude + n8n. Node names are on each step; the file is under the template.
Founder at Agentmelt
Reviews every build before it goes live; the workflow escalates to a person, never past one.
What is prior authorization?
Prior authorization automation treats the process as what it is — a documentation-assembly problem with a deadline: each order is checked against the payer’s rules to see whether authorization is required, the supporting documentation is gathered from the EHR, an AI agent drafts the medical-necessity summary against the payer’s published criteria with the gaps listed, the submission goes through the portal or by fax after a person’s click, the status is tracked, and denials get a drafted appeal. Everything runs on infrastructure under a business associate agreement with the model seeing the minimum necessary. The coordinator who spent a day a week per provider on auths spends it on the denials worth fighting.
- Prior authorizations take a coordinator a full day a week, per provider.
- Submissions go in incomplete and come back denied for a missing note.
- Nobody knows which auths are pending until the patient calls.
- Every payer has different criteria and they live in PDFs.
- Appeals are written from scratch, late, by whoever has time.
If two of these are yours, this is the process to look at first. Free audit — or read on.
What it looks like once it runs.
Prior authorization is a documentation-assembly problem with a deadline. The workflow checks each order against payer rules to see whether auth is required, gathers the supporting documentation from the EHR, has an AI agent draft the medical-necessity summary against the payer's published criteria, submits through the portal or fax with a person's click, tracks the status, and drafts the appeal when a denial comes back. Staff handle exceptions and clinical judgement; the paperwork runs itself.
- 11:30 An order is placed. The code, payer and plan are checked against the payer's rules: authorization required.
- 11:35 Notes, labs and imaging are gathered from the chart; each payer criterion is checked for what is missing.
- 11:45 A medical-necessity summary is drafted in the payer's own language with citations; staff click submit.
- Twice daily Status is checked; approvals go to scheduling. A denial comes back with a drafted point-by-point appeal.
Staff spend hours per day on payer portals and phone calls. Submissions go out incomplete and get denied for missing documentation; approvals take days; patients wait; and denials are appealed inconsistently or not at all.
Every order that needs auth is identified the day it is placed, the packet is complete against the payer's criteria before submission, status is tracked automatically, and denials get an appeal draft the same day. Turnaround shortens, first-pass approval rate rises, and staff time shifts from portals to patients.
Trigger, then 8 steps.
All eight steps run without anyone; a person sees only what the guardrails escalate.
EHR order event / daily order scan
Detect auth requirement
Order type, CPT/HCPCS code, payer and plan checked against the payer rules table (maintained from payer bulletins) to decide whether auth is needed and which form or portal applies.
Gather documentation
Relevant encounter notes, labs, imaging reports, prior treatments and diagnoses pulled from the EHR for the order's criteria checklist.
Check completeness against criteria
Each payer criterion (e.g. failed conservative therapy for 6 weeks, specific lab thresholds) checked against the documentation; missing items listed for the clinician.
Draft the medical-necessity summary
A structured summary mapping the documentation to each criterion in the payer's own language, with citations to the source notes; the clinician reviews and signs.
Submit
Through the payer portal API, a clearinghouse (Availity, Change Healthcare) or fax, after a staff member's click; the submission id and packet stored.
Track status
Twice-daily status checks; approvals written to the EHR and scheduling notified; pends trigger a documentation follow-up; denials trigger the appeal path.
Draft appeals
On denial, the agent reads the denial reason and drafts an appeal addressing it point by point with the evidence, for the clinician's review and signature.
Report
Turnaround, first-pass approval rate, denial reasons by payer, and appeal outcomes — the data for payer negotiations and process fixes.
No step waits for a person.
What the workflow hands to someone, by rule:
- Every submission and appeal is reviewed and signed by a clinician or authorised staff member; nothing is sent automatically.
Every order that needs auth is identified the day it is placed, the packet is complete against the payer's criteria before submission, status is tracked automatically, and denials get an appeal draft the same day
Every order that needs auth is identified the day it is placed, the packet is complete against the payer's criteria before submission, status is tracked automatically, and denials get an appeal draft the same day.
No decisions needed. Anything the guardrails flag is handed to a person; the rest ran alone.
Each pattern page explains it in plain words and lists every automation that uses it.
The template is built on n8n (how the n8n AI Agent node works); the same steps run on Make, Zapier or plain code. The tool is chosen to fit your accounts, you own the result, and the template comes in all three formats.
Data it touches
- EHR orders and clinical documentation (FHIR/HL7 or export)
- Payer rules and criteria (maintained table)
- Payer portals / clearinghouse APIs
- Denial and appeal history
Guardrails
- Every submission and appeal is reviewed and signed by a clinician or authorised staff member; nothing is sent automatically.
- PHI stays within HIPAA-covered infrastructure (self-hosted automation or a covered cloud, the model provider under a BAA); the model sees the minimum necessary.
- The summary maps documentation to criteria; it never asserts clinical facts that are not in the record.
- Payer rules are versioned and updated from bulletins; a rule change re-checks open requests.
Complete packets are the whole game
Most denials are for missing documentation, not medical reasons. Checking the packet against the payer's published criteria before submission — and telling the clinician exactly which item is missing — is what raises first-pass approval. The agent's summary then presents the evidence in the payer's own terms, which reviewers approve faster than a stack of notes.
HIPAA posture
Everything in this workflow touches protected health information, so it runs on covered infrastructure: self-hosted automation or a cloud under a BAA, a model API under a BAA, minimum-necessary data to the model, full audit logging, and human review of every outbound document. Your compliance officer signs off on the data-flow diagram before go-live; it is part of setup.
What it connects to.
| Tool | Role in this workflow |
|---|---|
| n8n (self-hosted) | Order intake, criteria check, submission, tracking |
| Claude (under BAA) | Necessity summaries and appeal drafts |
| EHR (Epic, athenahealth, eClinicalWorks…) | Orders and documentation |
| Availity / payer portals | Submission and status |
Want this running without building it?
$249
This one handles regulated data, so it is not hosted by us: we install the standard version in your own account within two working days of access, with a recorded walkthrough and 30 days of fixes, and it stays yours. Ongoing maintenance is scoped with the plan.
$8,000–15,000 one-time
Your systems, your rules, your edge cases. A one-off build delivered into your accounts to keepon Claude and n8n, delivered into your accounts to keep, with documentation and a recorded walkthrough.
The subscription suits practices with EHR API access and up to 300 auths a month; most deployments are custom because of EHR integration and BAA requirements.
Also sold one-time, installed in your own accounts, as part of the healthcare providers package and the operations teams package — do it yourself $49 · installed for you $249 · done for you $490.
When this becomes a custom build.
The subscription covers the standard version — $297/month, setup and maintenance included. Three things move it to a custom build ($8,000–15,000 one-time), delivered into your accounts to keep. If one of them is you, say so on the audit and the plan prices both.
EHR integration — most practices need it, and it needs a BAA and a build against your EHR’s API.
Payer portals without an API, where submission has to be automated through the browser.
Above 300 authorisations a month, or several specialities with different documentation rules.
Running the standard version first is the usual path: the exceptions it logs in the first month are the scope of the custom build, with your own numbers. How custom builds work.
Frequently asked questions.
Does it submit authorisations automatically?
It prepares and, after a staff member's click, submits. Status tracking and follow-ups are automatic; every outbound document is reviewed by a person.
Which EHRs and payers?
EHRs with FHIR or export capability (Epic, athenahealth, eClinicalWorks, NextGen, Cerner); payers via Availity, Change Healthcare or their own portals and fax. Payer rule tables are built for your top payers during setup.
Is the model HIPAA-compliant?
Anthropic offers a BAA for Claude API use in covered workloads; the workflow sends the minimum necessary data and logs every call. The full architecture is reviewed with your compliance officer.
Does prior authorization automation submit authorizations on its own?
No — it assembles the complete submission and a person clicks; the click is where a coordinator confirms the documentation and the criteria match. Portals without a usable connection are automated through the browser as a custom build; fax goes out from the practice’s fax service after the same click.
Which EHRs and payers does it work with?
EHRs with a usable connection under a BAA — Epic, athenahealth, eClinicalWorks, NextGen and others — as a build against your instance; payer criteria are loaded from the payers you submit to most, and added as new ones appear. Above 300 authorizations a month, or specialty-specific criteria libraries, are custom builds.
Is the AI model HIPAA compliant?
The deployment is: the workflow runs on covered infrastructure, the model provider signs a business associate agreement, the model sees the minimum necessary — the clinical facts for the summary, not the whole chart — and every access is logged. Ask for the BAA and the data-flow diagram; both exist for this workflow.
What this blueprint is built on.
Vendor documentation the steps rely on, and the rules the guardrails are written against.
- CMS — Interoperability and Prior Authorization Final Rule (CMS-0057-F) www.cms.gov/priorities/key-initiatives/burden-reduction/interoperability/policies-and-regulations/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f
- HHS — HIPAA for professionals www.hhs.gov/hipaa/for-professionals/index.html
- Availity — payer connectivity www.availity.com/