Does prior authorization automation use browser bots or portal logins?

No. RCM Employee is API-first only. Prior authorizations are submitted as 278 EDI transactions through clearinghouses such as Stedi and Availity. There is no browser automation, screen scraping, or portal-login bot involved, which keeps the workflow auditable and HIPAA-safe.

Will the AI submit a prior auth without human review?

No. A human-in-the-loop approval gate sits before every submission. The Prior Authorization Digital FTE detects requirements, assembles medical-necessity justification and supporting documents, and stages the 278 — but a person approves before anything is sent to the payer.

How much does AI prior authorization automation cost?

Pricing is credit-based pay-as-you-go with a $250/month minimum. Fixed-salary plans are also available: Standard at $3,500/month for business-hours coverage and Professional at $5,500/month for 24/7 coverage. All plans include the full team of 12 Digital FTEs.

Prior Authorization Automation: AI Prior Auth & 278 EDI (2026 Guide)

Prior auth is the slowest, most denial-prone step in the revenue cycle. AI can detect it, justify it, and submit it — without a single portal login.

Short answer: RCM Employee automates prior authorization with a dedicated Prior Authorization Digital FTE. It detects when a CPT or service needs auth, builds medical-necessity justification from CMS coverage and payer rules, and submits the 278 EDI transaction through clearinghouses like Stedi and Availity — all API-first, HIPAA-compliant, and gated by human approval before anything reaches the payer.

What prior authorization automation actually does

Manual prior auth means staff cross-checking payer lists, logging into portals, faxing clinical notes, and chasing status for days. Automation collapses that into a deterministic, API-first workflow. The Prior Authorization Digital FTE runs the full lifecycle: requirement detection, medical-necessity assembly, electronic submission, status tracking, and follow-up — surfacing only the decisions a human needs to make.

Auth requirement detection — flags when a CPT/HCPCS code or service requires authorization for the specific patient's payer and plan.
Medical-necessity justification — pulls CMS coverage (LCD/NCD) and payer-specific rules to build the supporting rationale.
278 EDI submission — sends the standardized prior authorization request electronically through Stedi or Availity.
Status tracking — monitors pending, approved, and denied determinations and routes exceptions back to staff.
Retro-auth & peer-to-peer prep — packages the clinical record for retroactive authorizations and prepares talking points for peer-to-peer reviews.

API-first, never a browser bot

RCM Employee is API-first by design. Prior authorizations move as 278 EDI transactions through clearinghouse APIs — not through screen scraping, robotic portal logins, or browser macros that break every time a payer redesigns a page. Where a payer requires supporting clinical documentation outside EDI, the system submits it via HIPAA-compliant fax (SRFax) or HIPAA-compliant email (AWS SES). This keeps every transaction encrypted, deterministic, and fully auditable.

The 278 EDI transaction, explained

The 278 is the X12 EDI standard for health care services review — the electronic format payers accept for prior authorization and referral requests. Instead of a fax queue or a portal form, the request travels as structured data: subscriber, provider, service codes, dates, and justification. The payer returns a 278 response with an approval, a pended status, or a denial reason. Because it is structured, the AI can read the response, update tracking automatically, and trigger the next action without manual re-keying.

Human-in-the-loop before every submission

Important: Nothing is submitted to a payer autonomously. A human approval gate sits in front of every 278. The Digital FTE prepares the complete request — codes, justification, attachments — and a staff member reviews and approves it before it is sent. This keeps clinical and compliance accountability with your team while removing the repetitive prep work.

This human-in-the-loop model is deliberate. Prior auth carries clinical and financial consequences, so the AI does the assembly and the human owns the decision — the best of speed and oversight.

HIPAA compliance and security

Prior auth touches PHI on every request, so security is foundational, not optional:

Encryption everywhere — data encrypted at rest with AWS KMS and in transit with TLS.
Per-practice isolation — each practice's data is scoped and isolated from every other tenant.
BAA chain — Business Associate Agreements across every PHI-touching service.
7-year audit log — every action is recorded in an immutable audit trail for compliance review.

Who it's for

The Prior Authorization Digital FTE fits U.S. solo and group practices, specialty clinics, nurse practitioners, behavioral health providers, and hospital outpatient departments — anywhere high auth volume, frequent denials, or imaging/procedure-heavy schedules make manual prior auth a bottleneck. It works alongside the other 11 Digital FTEs covering eligibility, coding, claims, denials, and the rest of the revenue cycle.

Frequently asked questions

Does prior authorization automation use browser bots or portal logins?: No. RCM Employee is API-first only. Prior authorizations are submitted as 278 EDI transactions through clearinghouses such as Stedi and Availity — no browser automation, screen scraping, or portal-login bots. That keeps the workflow auditable and HIPAA-safe.
Will the AI submit a prior auth without human review?: No. A human-in-the-loop approval gate sits before every submission. The Digital FTE detects requirements, assembles justification and documents, and stages the 278 — but a person approves before anything is sent to the payer.
Can it handle retro-authorizations and peer-to-peer reviews?: Yes. It packages the clinical record to support retroactive authorization requests and prepares the medical-necessity talking points your provider needs for a peer-to-peer review.
How much does it cost?: Credit-based pay-as-you-go with a $250/month minimum, plus fixed plans: Standard at $3,500/month (business hours) and Professional at $5,500/month (24/7). Every plan includes all 12 Digital FTEs.

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