Prior Authorization Workflow
Agentic workflow that turns a free-text prior authorization request into a policy-grounded approve, deny, or pend decision — with low-confidence cases routed to a clinician.
Try WorkflowWorkflow Architecture
Key Components
Security & Safety
Context
Prior authorization is a bottleneck in healthcare workflows—clinicians spend hours manually compiling patient data, insurance requirements, and medical evidence to submit authorization requests. The process is error-prone, delays patient care, and creates friction for providers.
What I built
Built an agentic workflow on Dify that structures a free-text request into fields, retrieves the governing payer CPT policy, gathers medical-necessity and step-therapy evidence through MCP tool calls, and issues an approve, deny, or pend decision with a confidence score.
Two gates keep it honest. A completeness check stops underspecified requests before any clinical reasoning runs, returning the specific missing fields. A confidence gate withholds any decision scoring below 8 out of 10, routing it to a clinician with a documented action checklist instead of issuing it automatically.
Outcome
The workflow produces a policy-grounded recommendation with cited evidence, not a submitted authorization—a human remains responsible for the filing. The agent architecture is reusable for other payer and coverage-determination workflows.