AI-Powered Prior Authorization

PA Prep in 75 Seconds.
Not 75 Minutes.

AI-powered prior authorization preparation built for infusion centers. Upload a referral, get a submission-ready package with every requirement checked, every gap identified, and a clinical summary letter ready to print.

Request a Demo 15-minute walkthrough See It In Action
75s
Processing time
48
Drugs covered
99%
Accuracy
98
Drug-specific alerts

*Processing time measured on standard referral documents. 48 drugs across BCBSTX formulary with multi-payer expansion in progress. Accuracy target based on extraction + policy matching. 98 drug-specific alerts cover step therapy, labs, biosimilar requirements, dosing, and payer-specific gotchas.

The Problem

Prior Auth Is Crushing
Your Infusion Center

Your staff spends more time fighting payer requirements than caring for patients. Every denied authorization means delayed treatment, lost revenue, and frustrated physicians.

45+
Minutes per PA
request manually
30%
Average initial
denial rate
$11B
Annual industry cost
of prior auth burden
93%
Of physicians say PA
delays patient care
How It Works

Three Steps to Faster Approvals

No integration headaches. No months-long onboarding. Upload a referral and see results immediately.

1

Upload the Referral

Drop in the specialist referral PDF, or batch upload up to 25 at once. No reformatting needed.

2

AI Analyzes in ~60 Seconds

Dedicated AI engines analyze against 48 drugs and 98 drug-specific alerts, matching payer requirements in real time.

3

Review, Print, Submit

Review the coordinator checklist, print the PA package, and submit to the payer via portal or fax.

Interactive Demo

See What Your Coordinator Gets

Click through the three phases of a real PA preparation — from referral upload to submission-ready package.

AIHC Auth — Prior Authorization Engine
📄
Drop referral document here
PDF Thompson_Referral_Remicade.pdf (2.3 MB)
✓
Reading your document...
✓
Checking payer requirements...
✓
Preparing your package...
Analysis Complete — Remicade (Infliximab) • Rheumatoid Arthritis

Authorization submission possible but biosimilar step-through requirement not met. Obtain biosimilar trial documentation or physician attestation before submitting.

12
Requirements met
2
Still missing
78.5%
Doc quality
35%
Denial risk
14.2s
Analysis time
NEARLY READY
BCBSTX  ·  Direct Auth
15 biz day turnaround
⚠ Fix 2 missing items before submission — see checklist below
Auth: 1-800-451-0287
Missing Items (2)
⚠
Biosimilar step-through HIGH
BCBSTX requires trial of infliximab biosimilar before brand Remicade. Document prior biosimilar use or obtain physician attestation of contraindication.
⚠
Fresh inflammatory markers MEDIUM
CRP/ESR labs >90 days old. BCBSTX prefers labs within 30 days of submission. Order new labs before submitting.
Confidence Flags — Verify Before Submission (2)
Click any flag to view the source document page and verify the extracted value.
⚠
step_therapy_met  80% confidence  Pages 6–7
Value: "partial" — Verify step therapy documentation is complete before submission
View in doc →
⚠
tb_screening  72% confidence  Page 8
Value: "QuantiFERON Gold: Negative (2025-11-15)" — Confirm original lab report is in chart
View in doc →
Drug-Specific Alerts (4)
Biosimilar step-through required for NEW starts Critical
BCBSTX requires trial of infliximab biosimilar before brand Remicade for new patients. Existing patients stable on Remicade may be grandfathered. Document whether this is a new start or continuation.
Clinical Evidence
●
NOR-SWITCH Trial (JAMA 2017)
First RCT for infliximab biosimilar switching (n=481). RA subgroup showed increased disease worsening trend in switched arm. Non-inferiority not established in all subgroups.
●
FDA Interchangeability Gap (Q1 2025)
Zero infliximab biosimilars hold FDA interchangeable designation. Pharmacist auto-substitution is not permitted — substitution requires physician clinical judgment per patient.
●
Genovese et al. (Ann Rheum Dis 2019)
15% anti-drug antibody (ADA) formation rate in RA patients switched from originator infliximab to biosimilar while previously stable.
●
ACR Position Statement (2018, reaffirmed 2022)
Non-medical switching of stable biologic patients not recommended without patient consent, physician oversight, and a clinical monitoring plan.
Medical Necessity Arguments
  • Patient is clinically stable on brand Remicade — non-medical switching introduces immunogenicity risk with no clinical benefit.
  • No infliximab biosimilar holds FDA interchangeable status — substitution is a medical decision, not a formulary one.
  • BCBSTX biosimilar-first policy applies to NEW starts. Existing stable patients are eligible for grandfathering — document continuity of care.
  • ACR and rheumatology societies oppose non-medically indicated switching of clinically stable patients.
First-Submit Appeal Strategy
Frame as "medically necessary continuation," not "biosimilar refusal." Lead with stability duration and documented disease control. Cite the FDA interchangeability gap. If denied, this is among the strongest P2P cases in rheumatology — request peer-to-peer review immediately.
Weight required for dose calculation Critical
Remicade is weight-based (3–5 mg/kg depending on indication). Missing weight = automatic denial. Must be documented within 30 days of submission.
Concurrent methotrexate recommended for RA High
For RA indication, concurrent methotrexate improves efficacy and reduces anti-drug antibody formation. BCBSTX may question why MTX is not co-prescribed. Document rationale if MTX is contraindicated.
Loading dose schedule must be specified High
Remicade requires loading doses at weeks 0, 2, and 6 before maintenance every 8 weeks. PA must request all loading doses upfront or they may only approve a single dose.
⚖
Clinical Justification Engine
AI-assembled defense against biosimilar step-through requirement
STRONG CASE — Level 1 RCT
How the AI built this argument
1
Drug classified → Remicade (Infliximab) — RA indication confirmed
2
Payer policy scanned → BCBSTX biosimilar-first requirement detected (new starts only)
3
Patient status flagged → Existing stable patient — grandfathering pathway applies
4
Evidence queried → 6 peer-reviewed sources retrieved across 4 evidence tiers
5
Argument structured → Medical necessity justification assembled + appeal letter pre-loaded
Evidence assembled by tier
Tier 1 — RCT (Strongest)
NOR-SWITCH Trial — JAMA 2017
First and largest RCT for infliximab biosimilar switching (n=481). RA subgroup showed increased disease worsening trend in switched arm.
Tier 2 — Real-World Registry Data
DANBIO Registry — Glintborg et al. (Ann Rheum Dis 2017)
National registry of 802 RA/SpA/PsA patients. 17.6% discontinuation at 12 months; primary reason: perceived lack of efficacy.
Tier 2 — Observational Study
Genovese et al. — Ann Rheum Dis 2019
15% anti-drug antibody (ADA) formation rate in RA patients switched from originator infliximab to biosimilar while previously stable.
Tier 3 — Regulatory Position
FDA Interchangeability Gap — Current as of Q1 2025
Zero infliximab biosimilars hold FDA interchangeable designation. Substitution decisions remain physician clinical judgment per patient.
Tier 4 — Society Guidelines
ACR Position Statement (2018, reaffirmed 2022) • EULAR 2020
Both ACR and EULAR oppose non-medical switching of clinically stable biologic patients without patient consent and physician oversight.
This evidence is pre-loaded into your appeal letter — ready to submit if denied
Coordinator Pre-Submission Checklist
Analysis Details ▼
Payer
Blue Cross Blue Shield of Texas (BCBSTX)
Auth System
Direct to BCBSTX (NOT eviCore)
Auth Contact
1-800-451-0287
Standard Turnaround
15 business days
Expedited Turnaround
3 business days
Denial Risk
MEDIUM — 35%
ICD-10 Codes
M05.79, M06.09
Site of Care Risk
LOW — Infusion center appropriate. No site-of-care concern.
Gold Carding
Not yet eligible. Eligibility builds after 3 successful approved PAs for this drug/payer combo.
Next Steps (3 actions) ▼
1
Biosimilar documentation
Contact Dr. Chen to obtain documentation of prior biosimilar trial/failure OR letter of medical necessity for brand Remicade. Priority: Before submission.
2
Fresh labs
Order new CRP and ESR labs. BCBSTX prefers labs within 30 days of submission.
3
Submit to BCBSTX
Once biosimilar documentation and fresh labs are obtained, submit via BCBSTX provider portal or call 1-800-451-0287.
Pipeline Stages — 15 agents · 14.2s total ▼
StageStatusDetailsTime
Text Extractioncomplete18,420 chars · 12 pages · 3 OCR1.2s
Clinical Interpretationcomplete4 corrections · 1 ambiguity resolved2.1s
8 Reader Agentscomplete8 readers run · 0 failed · parallel2.4s
Cross-ValidationcompletePassing · 1 low-severity issue1.8s
Quality GatecompletePassing · 78.5% doc score0.9s
Extraction AuditcompletePassed · 2 findings (0 critical)1.1s
Eligibility VerificationcompleteEligible · BCBSTX PPO confirmed0.8s
Drug Classificationcompleteremicade · 98% confidence0.6s
Urgency DetectioncompleteROUTINE · 0 triggers0.4s
Policy MatchingcompleteBCBSTX / Remicade · 4-layer3.2s
Matcher AuditcompletePassed · 0 false positives/negatives0.9s
Readiness AggregationcompleteYELLOW · 12/14 met1.1s
Denial PredictioncompleteMEDIUM risk · 35% probability1.1s
Next Stepscomplete3 actions generated0.8s
Clinical Summary LettercompleteLetter generated · 480 words2.2s
PA Preparation Package
8 Docs Included  |  2 Missing  |  10 Form Fields
  • ✓
    Signed Physician Order pg. 1
    Signed by Dr. A. Nguyen, MD — dated March 18, 2026
    Source: Page 1, top of referral • Includes NPI, prescriber signature, and date
  • ✓
    Clinical Summary Letter auto-generated
    AI-generated letter summarizing medical necessity, diagnosis, prior therapies, and treatment plan
    Auto-generated from extracted referral data • 1 page • Formatted for payer review
  • ✓
    Disease Activity Assessment pg. 5
    DAS28-CRP: 5.1 (high disease activity) — documented February 2026
    Source: Page 5, rheumatology assessment • Supports medical necessity
  • ✓
    Prior Therapy Documentation pg. 3-4
    Methotrexate 20mg/week x 16 weeks — inadequate response documented
    Source: Pages 3-4, clinical notes • Satisfies BCBSTX step therapy requirement
  • ✗
    TB Screening REQUIRED
    Last result found on page 6 — dated 2025-01-15 (expired, must be within 12 months)
    Action needed: Order new QuantiFERON-TB Gold Plus test
    Why: BCBSTX requires TB screening within 12 months prior to biologic initiation
  • ✗
    Hepatitis B Panel REQUIRED
    Searched all 12 pages — no HBsAg, anti-HBs, or anti-HBc results found
    Action needed: Order Hepatitis B panel (HBsAg, anti-HBs, anti-HBc)
    Why: Required for all TNF inhibitors per BCBSTX medical policy
Clinical Summary Letter Preview
PRIOR AUTHORIZATION PREPARATION PACKAGE
Generated: March 23, 2026
Patient: R. Thompson | Member ID: XEH***
Drug: Remicade (infliximab) 5mg/kg IV
Diagnosis: M05.79 - Rheumatoid arthritis w/ rheumatoid factor
Prescriber: Dr. A. Nguyen, MD | NPI: 1234567890
Facility: Medix Infusion Center | TIN: ***-**-4521

CLINICAL JUSTIFICATION:
Patient is a 52-year-old female with seropositive RA (RF+,
anti-CCP+). DAS28-CRP score 5.1 indicates high disease
activity despite 16 weeks of methotrexate 20mg/week.
Biologic therapy with Remicade is medically necessary per
ACR guidelines for moderate-to-severe RA with inadequate
response to conventional DMARDs.
Click to expand full letter
▶ View Full Package Text 
═══════════════════════════════════════════════
  PRIOR AUTHORIZATION PREPARATION PACKAGE
  BCBSTX — Direct Prior Authorization
═══════════════════════════════════════════════

PATIENT INFORMATION
  Name:       R. Thompson
  DOB:        ██/██/1974
  Member ID:  XEH██████
  Group:      ████████

PRESCRIBER INFORMATION
  Name:       Dr. A. Nguyen, MD
  NPI:        1234567890
  Phone:      (214) 555-████
  Fax:        (214) 555-████

MEDICATION REQUESTED
  Drug:       Remicade (infliximab)
  J-Code:     J1745
  Dose:       5 mg/kg (375 mg based on 75 kg)
  Route:      Intravenous infusion
  Frequency:  Weeks 0, 2, 6, then q8 weeks
  Duration:   12 months

DIAGNOSIS
  Primary:    M05.79 — RA w/ rheumatoid factor, multiple sites
  Supporting: M06.09 — RA without rheumatoid factor

CLINICAL JUSTIFICATION
  Patient is a 52-year-old female with seropositive RA
  (RF+, anti-CCP+). DAS28-CRP score of 5.1 indicates
  high disease activity. Failed adequate trial of
  methotrexate 20mg/week x 16 weeks with documented
  inadequate response.

STEP THERAPY DOCUMENTATION
  ✓ Methotrexate 20mg/week — 16 weeks — inadequate
  ✓ Documented on referral pages 3-4

SUPPORTING DOCUMENTS INCLUDED
  ✓ Signed physician order (pg. 1)
  ✓ Clinical summary letter (auto-generated)
  ✓ Disease activity assessment (pg. 5)
  ✓ Prior therapy documentation (pg. 3-4)
  ✗ TB screening — EXPIRED (needs reorder)
  ✗ Hepatitis B panel — NOT FOUND (needs order)

SUBMISSION INFORMATION
  Portal:  availity.com
  Fax:     1-800-924-7141
  Phone:   1-800-441-9188

═══════════════════════════════════════════════
  Prepared by AIHC Auth | aihcauth.com
  This document is for PA preparation only.
  Submit through your normal payer channel.
═══════════════════════════════════════════════
This is what your coordinator gets -- ready to print and submit.
Drug Coverage

We Know Your Drugs

48 infusion and injection medications across 6 categories, with multi-payer support (BCBSTX live, Aetna in progress). Each drug has its own dedicated AI engine with 98 drug-specific gotcha alerts, payer-specific approval logic, and a 10-item coordinator pre-submission checklist.

Rheumatology

13

Remicade, Orencia, Actemra, Rituxan, Simponi Aria, Cimzia, Inflectra, Benlysta, Saphnelo, Krystexxa, Cosentyx IV, Jubbonti, and more

Neurology

12

Ocrevus, Tysabri, Briumvi, Uplizna, Radicava, Vyvgart, Rystiggo, IVIG, SCIG, HyQvia, Ultomiris, Vyepti

Gastroenterology

6

Entyvio, Stelara IV, Skyrizi IV, Omvoh, Tremfya, Amvuttra

Pulmonology

6

Xolair, Nucala, Fasenra, Tezspire, Alpha-1 PI, Cinqair

Dermatology

3

Ilumya, Spevigo, Imaavy

Other Specialties

8

Tepezza, Leqvio, Injectafer, Rezzayo, Soliris, Prolia, Crysvita, Actemra Pediatric

Each drug has dedicated approval logic, step therapy validation, and payer-specific denial prevention.
Get Started Today

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MISSING INFORMATION REQUEST — PREVIEW
MEDIX INFUSION
Prior Authorization Support Team • (555) 210-4400 • Fax: (555) 210-4401
TO: Dr. Sarah Mitchell — Rheumatology Associates • Fax: (555) 874-2200 FROM: Medix Infusion PA Team DATE: PAGES: 1 (this page only) RE: Patient: M.J. • DOB: [on file] • Insurance: BCBSTX • Drug: Remicade (Infliximab)

Dear Dr. Mitchell's Office,

We are preparing a prior authorization request for the above-referenced patient for Remicade (Infliximab) through Blue Cross Blue Shield of Texas. Our clinical review has identified the following items that are required for submission. Please provide the documentation noted below at your earliest convenience.

Items Required — 2 Outstanding
1.
Biosimilar Step-Therapy Documentation High Priority
BCBSTX requires documentation of a prior trial of an infliximab biosimilar for new Remicade starts, OR a signed physician attestation that biosimilar therapy is medically contraindicated for this patient.

Please provide one of the following:
• Records documenting prior biosimilar trial (drug name, dates, reason discontinued)
• Signed letter of medical necessity / attestation of biosimilar contraindication
2.
Current Inflammatory Markers Medium Priority
Lab results on file (CRP/ESR) are greater than 90 days old. BCBSTX requires laboratory values within 30 days of the prior authorization submission date.

Please provide:
• CRP and/or ESR results dated within the last 30 days
• Acceptable formats: lab printout, EMR export, or office note with documented values

Please return documentation to our fax at (555) 210-4401 or call (555) 210-4400 with any questions. We will submit the prior authorization as soon as all items are received. Thank you for your prompt attention.

Medix Infusion — Prior Authorization Support Team
This fax is intended solely for the use of the individual or entity to which it is addressed and may contain confidential information.