Prior authorization is a payer workflow used to review whether a service, medication, device, or procedure meets coverage requirements before it is provided or paid. It can involve clinical documentation, eligibility information, payer portals, and follow-up communication.
AI tools may help gather documentation, draft requests, check status, or prioritize work queues. Reviewers should verify payer coverage, accuracy, auditability, human review, and PHI safeguards.
Application scenario: In operational review, this term helps teams connect a vendor claim to the revenue, access, staffing, patient communication, or payer workflow where it applies. Procurement impact: Buyers should evaluate evidence, implementation effort, pricing assumptions, reporting, security, privacy, support, and compliance responsibilities before shortlisting or contracting for a tool that depends on this capability.