Case Study — Nexora
Cutting Prior-Authorization Turnaround From 6 Days to Under 24 Hours Across 40 Payers
AI agents assembling clinical evidence and predicting approval likelihood before submission
Industry
Multi-Specialty Health System
Timeline
16 weeks
Team
6 engineers
Tech
Multi-Agent Orchestration + FHIR + PostgreSQL
The Challenge
A multi-specialty health system's prior-authorization team was manually assembling clinical documentation for every payer request across 40 different insurance payers, each with its own submission format and medical necessity criteria. Average turnaround was 6 days, staff re-entered the same clinical data into different payer portals all day, and 22% of submissions were denied purely on documentation technicalities, not clinical merit.
Our Approach
How We Solved It
Payer Rule Ingestion Agent
Built an agent that ingests and normalizes medical necessity criteria across all 40 payers into a structured, queryable rule set, replacing a shared spreadsheet nobody kept current.
Clinical Evidence Assembly Agent
Deployed an agent that pulls relevant clinical notes, lab results, and prior treatment history from the EHR via FHIR and assembles a payer-specific evidence packet automatically.
Approval-Likelihood Scoring
Before submission, the workflow scores each request's approval likelihood against the specific payer's criteria, flagging weak submissions for a clinician to strengthen before it's ever sent — not after a denial.
Payer-Specific Submission Formatting
Automated formatting and submission to each of the 40 payer portals' distinct required formats, eliminating the manual re-entry that consumed most of the team's day.
Engineering Process
How We Built It
FHIR-Native Data Access
All EHR data access runs through FHIR resources rather than direct database queries, so the integration survives EHR vendor upgrades without custom maintenance.
Per-Payer Rule Versioning
Each payer's medical necessity criteria is versioned independently, since payers update requirements on their own schedules — a change from one payer never risks breaking another's workflow.
PHI-Scoped Agent Memory
Agent context windows are scoped per-patient-per-request and discarded after submission, so no clinical data persists in agent memory beyond what a specific authorization requires.
Architecture Decisions
Key Technical Choices
Clinician Review Before Every Submission
The workflow always routes the assembled packet to a clinician for review before submission — the agents assemble and score, they never submit unreviewed clinical justification.
SOC 2 & HIPAA-Aligned Audit Logging
Every data access, agent action, and clinician override is logged against Nexora's compliance-grade audit trail, which was the deciding factor in the health system's security review.
Payer Integration as Pluggable Adapters
Each payer's portal integration is a pluggable adapter behind a common interface, so onboarding payer #41 doesn't require touching the other 40.
Results
What We Delivered
Solution Blueprint
How It All Fits Together
- FHIR-native EHR access
- Per-payer rule versioning
- PHI-scoped agent memory
- Clinical evidence assembly agent
- Approval-likelihood scoring
- Payer-format submission agent
- Clinician review queue
- Prior-auth staff dashboard
- Compliance audit exports
Lessons Learned
What We Improved
Score Before Submission, Not After Denial
The single highest-impact change was scoring approval likelihood before submission rather than analyzing denials afterward — it moved the intervention point upstream.
Payer Rule Drift Is Constant
Payers change requirements without much notice. Building a lightweight rule-update workflow for the prior-auth team — not engineering — to maintain was essential for staying current.
Clinicians Need to See the 'Why'
Surfacing exactly which criteria a request was weak against, not just a score, is what got clinicians to actually act on the flag before submission.
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