Healthcare administration
Which prior-auth and claims decisions can follow the rule book, and which need a clinician?
For payers, providers and the administrators between them. Much of the work is checking a request against written criteria under a deadline. Clinical judgement is a different job, and it stays with clinicians.
What to compile, what to keep on a model, what to leave alone
Typical calls, not a verdict on your workflow. The Workflow Diagnostic decides yours, on your own cases.
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Prior-authorisation completeness and criteria checks
Compile into codeIs the request complete, and does it meet the written criteria? Rules that must give the same answer for the same request, inside the decision deadline.
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Claims edits
Compile into codeCoding and policy edits are rules, and each rejected line needs the rule that rejected it.
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Eligibility checks
Compile into codePlan, benefit and date rules with a clear answer.
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Pulling facts from clinical documents
Keep with an AI modelReading clinical notes is language work. A model extracts the facts inside a schema for a reviewer to confirm.
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Medical-necessity decisions
Don’t automateA clinician decides. Automation prepares the file and records the decision.
What your regulator or auditor will ask
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CMS’s Interoperability and Prior Authorization Final Rule (CMS-0057-F, January 2024) requires Medicare Advantage, Medicaid and CHIP payers to decide prior authorization requests within 72 hours (expedited) and 7 calendar days (standard), starting 1 January 2026. Most of the rule’s API requirements apply from 1 January 2027.
Source: CMS fact sheet, 17 January 2024
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The HIPAA Privacy and Security Rules apply to covered entities (health plans, health care clearinghouses and providers who transmit health information electronically) and to their business associates that handle protected health information.
Source: U.S. Department of Health and Human Services
Last reviewed: 11 October 2026 by the IOanyT advisory team. This is general information, not legal advice.
Closest work we can show
Chosen by the kind of problem, not the industry. Each case says which sector it comes from.
Old system holding the rules?
Claims and practice-management systems often carry years of payer rules in code nobody has documented. Specify them before you replace anything.
Legacy System Specification AssessmentHow we’d start
- 1. AI Reliability Review. Free, 60–90 minutes, a 2-page findings note you keep.
- 2. Workflow Diagnostic. Two to three weeks to decide what to compile, keep on a model or leave alone.
Fixed price, agreed at scoping. Stop after any step. The findings are yours.
Tell us which decision is stuck.
We'll tell you in writing whether we can help.
Book a Reliability ReviewFree · 60–90 minutes · a 2-page findings note you keep