Prior Authorization Automation

Challenge – Manual Processes Delaying Care
The payer faced major inefficiencies in its prior authorization (PA) process, with manual data entry, incomplete documentation, and multi-step validation across systems. This caused delays in patient care, 20% denial rates, and increased administrative overhead for a member base of more than 500,000 individuals.

Solution – Automated Prior Authorization with AI
NucleusTeq implemented a Document AI solution using Quantum (NuoData) to automate the end-to-end PA lifecycle — from document intake and medical necessity evaluation to automated routing for approval. Integrated through FHIR APIs, the system synchronized seamlessly with EHR and payer systems. It also applied rule-based and NLP-driven validation to identify missing data and prevent errors before submission.

Impact – From Delays to Real-Time Decisions
• 35% faster prior authorization turnaround
• 20% increase in approval rates
• 15% reduction in denials
• $1M annual savings in administrative costs

The transformation streamlined provider-payer interactions, reduced friction in approvals, and improved member experience through faster, more transparent care authorization.