← Solution examplesHealth Care example · EHR ↔ Payer ↔ Scheduling
Prior Authorization Orchestration
The EHR knows what was ordered. The payer knows what it requires. Scheduling knows when the patient is coming. We make them operate as one workflow.
solution / prior-authorization-orchestration
Engineering blueprintLAYER 01Existing systemsIntegrated, not replaced
EHRPayer APIs / portalsClearinghouseSchedulingRevenue cycle
LAYER 02Governed episode dataCanonical, with lineage
OrdersRequirementsSubmissionsAppointments
LAYER 03KBSIntel orchestration layerState & workflow
Episode engineRequirement checksStatus sync
LAYER 04Decisions & intelligenceBuilt on governed data
Scheduling riskDenial reasonsAuthorization aging
01
Problem
Staff check payer requirements, gather EHR documentation, submit, follow up, and update scheduling by hand. When status drifts, patients arrive unauthorized and denials surface after the service.
02
Example
A procedure is scheduled for Tuesday. The payer requested more documentation through a portal nobody is watching. The schedule still shows ready.
03
Governed object · Authorization Episode
- Patient
- Order
- Payer / plan
- Requirement
- Documentation
- Submission
- Payer response
- Appointment
04
Where the systems disagree
- Unknown requirement
- Missing documentation
- Status drift
- Scheduling risk
- Unstructured responses
- Aging requests
05
State model
- ORDERED
- REQUIREMENT_CHECK
- DOCUMENTATION_REQUIRED
- READY_TO_SUBMIT
- SUBMITTED
- PAYER_REVIEW
- ADDITIONAL_INFORMATION
- APPROVED / DENIED
- SCHEDULED
06
What we build
An orchestration layer that keeps one authorization state across EHR, payer, and scheduling. It does not replace clinical or payer decisions.
- Authorization Episode model and status engine
- Requirement checks at order time
- Documentation completeness checks
- Submission tracking across payer APIs and portals
- Status sync back to EHR and scheduling
07
Controls
- Detect missing documentation before submission
- Identify requirements at order time
- Sync payer status with scheduling
- Escalate episodes at risk before the appointment
08
Intelligence
- Denial reasons by payer and service
- Scheduling risk for upcoming appointments
- Turnaround by payer
- Documentation gaps that trigger requests
09
What we'd measure
- Authorization turnaround by payer
- Appointments rescheduled for authorization
- Denials from missing documentation
- Staff hours on portal follow-up
Start with one problem. Engineer the right solution.
Manual work, systems that don't talk, data nobody trusts. We trace it to the source and ship the fix into production.