Current legacy prior authorization systems make the process complex and time consuming. Clinicians have to go through large volumes of documents to understand the clinical guidelines & medical necessity for a procedure.

Further, in order to ensure a good member experience it is imperative for Health plans to keep the TAT low on prior auth approvals. CMS requires that standard decisions be provided in 7 days and expedited ones within 72 hours.

CitiusTech's ePA solution accelerator helps Payers quickly setup rules in the CMS proposed CQL(Clinical Quality Language) by using the reusable repositories & the GenAI Assisted Rules acceleration Solution. It can be integrated seamlessly in to payers/providers existing workflows and helps in speeding up submission of prior auth forms, automated reviews and faster approvals.

Solution Features: CQL Rules & Repositories Building: Take Standard CMS based Policies/Rules and convert them into CQL based forms and Rules- CQL Mapping Libraries: Reusable libraries to map templates to various FHIR resources(e.g Patient addresses & Demographics mapping, Observation types mapping, etc) to enable automation GenAI Driven Clinical Rules Extraction: GenAI driven extraction of summarized clinical rules and the corresponding CQL format, from the Policy documents GenAI Driven CQL Rules,Questionnaire Generations: GenAI driven extraction of FHIR Based CQL Questionnaires to generate the UI equivalent of templates and forms.

Value Proposition Improved Efficiency : By eliminating manual process of verifying PA policies/guidelines against certain conditions, UM staffs are now able to process higher volume of prior authorization requests in the same timeframe. Effort and Time Saving: Leverage CitiusTech's GenAI Solution to cut down on time, effort and cost of the efforts in building the Automated Rules Reusability: The solution provides reusable assets & framework(e.g., CQL Libraires and Mapping functions) that help with re-usability and reduce duplicate efforts.

The AWS tech stack being leveraged for this solution are AWS API Gateway, Lambda, ECS, Kendra, BedRock, OpenSearch,TexTract