Documentation

Introduction

ParaHealth is an intelligent prior authorization platform built for healthcare providers, pharmacies, and payers. It automates the end-to-end PA workflow — from benefit verification through submission, appeals, and status tracking — so clinical and utilization-management staff can focus on patient care instead of paperwork.

Prior authorization remains one of the most time-consuming administrative burdens in healthcare. On average, a single PA takes 45 minutes of staff time, and roughly 30% of initial submissions are denied. ParaHealth reduces that time to under four minutes with a denial rate below 5%.

Manual PA vs ParaHealth

Platform Overview

ParaHealth is composed of three core layers that work together seamlessly:

• Data Ingestion Layer — Connects to EHR systems, pharmacy management software, and payer portals to gather patient records, formulary data, and payer policies in real time.
• AI Decision Engine — Uses NLP and clinical reasoning models to extract relevant clinical data, match it against payer criteria, and generate accurate answers to PA questions.
• Submission & Tracking Layer — Handles multi-channel submission (electronic, fax, portal) and provides real-time status tracking with automated follow-ups.

Benefit Verification Overview

Benefit verification (BV) is the process of confirming a patient’s insurance coverage, plan details, and medication eligibility before initiating a prior authorization. ParaHealth automates BV to eliminate phone-based manual checks and reduce claim rejections.

Eligibility Checks

ParaHealth performs real-time 270/271 eligibility transactions against payer systems to confirm:

• Active coverage status and effective dates
• Plan type (commercial, Medicare, Medicaid, managed care)
• Copay, coinsurance, and deductible details
• Out-of-pocket maximums and accumulator balances
• Pharmacy benefit vs. medical benefit routing

Formulary Lookup

Once eligibility is confirmed, ParaHealth queries the payer’s formulary to determine coverage tier, step-therapy requirements, and quantity limits for the prescribed medication.

• Tier classification (preferred, non-preferred, specialty)
• Step-therapy and fail-first requirements
• Quantity limits and days-supply restrictions
• Alternative medications on formulary

Real-Time Results

BV results are presented in a clear, structured format within the ParaHealth dashboard. Key outputs include:

• Coverage determination (covered, not covered, PA required)
• Estimated patient cost share
• PA requirement flag with payer-specific form references
• Recommended next steps based on coverage results

Prior Authorization Overview

Prior authorization is the process by which a payer reviews and approves a prescribed medication or procedure before it is dispensed or performed. It exists to manage costs and ensure clinical appropriateness, but has become a significant bottleneck in patient care delivery.

ParaHealth addresses every stage of the PA lifecycle: intake, question-answering, submission, tracking, and reauthorization.

Automated PA Workflow

The workflow proceeds through five stages, mirroring the steps shown in the product demo on the homepage:

AI Answer Generation

The AI engine reads each payer question, searches the patient’s clinical record for supporting evidence, and generates a concise, clinically appropriate answer. Each answer includes:

• A direct response to the payer’s question
• Citations to specific clinical records (lab results, chart notes, diagnoses)
• A confidence score indicating how strongly the evidence supports the answer
• Flags for any missing information that may weaken the submission

Denial Risk Detection

Before submission, ParaHealth evaluates the completed PA against historical denial patterns for the specific payer, drug, and diagnosis combination. The system flags submissions that have a higher probability of denial and recommends corrective actions:

• Adding supporting documentation (lab values, imaging reports)
• Strengthening clinical justification language
• Attaching peer-reviewed literature references
• Requesting a peer-to-peer review proactively

Omni-Channel Submission

ParaHealth routes each PA to the payer through the most effective channel available:

• Electronic PA (ePA) — Direct NCPDP SCRIPT integration for real-time electronic submission and response.
• Payer Portal — Automated form completion and submission through payer web portals via secure browser automation.
• Fax — Generated PDF forms submitted via integrated fax service with delivery confirmation.

Status Tracking

All submitted PAs are tracked in a centralized dashboard with real-time status updates. The system automatically polls payer systems for determination results and sends notifications when statuses change. Tracked states include:

• Submitted / Pending Review
• Additional Information Requested
• Approved / Approved with Modifications
• Denied (with denial reason codes)
• Appeal in Progress

Inbound Fax Parsing

Many payers still respond to PA requests via fax. ParaHealth automatically receives, OCRs, and parses inbound fax responses to extract determination results, approval durations, and any conditions or restrictions. Parsed data is matched to the originating PA and the status is updated accordingly.

Appeals Workflow

When a prior authorization is denied, ParaHealth streamlines the appeals process to maximize overturn rates while minimizing staff effort. The system guides clinical staff through each stage of the appeal — from initial review of denial reasons through final determination.

Automated Appeal Preparation

Upon receiving a denial, ParaHealth immediately analyzes the denial reason codes and generates an appeal strategy:

• Parses denial reason codes to identify the specific deficiency cited by the payer
• Searches the patient’s clinical record for additional supporting evidence not included in the original submission
• Drafts an appeal letter with strengthened clinical justification tailored to the denial reason
• Attaches relevant peer-reviewed literature, clinical guidelines, and supporting documentation
• Recommends whether to pursue a written appeal, peer-to-peer review, or external review based on denial type and payer history

Peer-to-Peer Review Coordination

For denials eligible for peer-to-peer review, ParaHealth prepares the requesting clinician with:

• A summary of the payer’s stated denial rationale
• Key clinical talking points drawn from the patient’s record
• Relevant guideline citations that support medical necessity
• Historical peer-to-peer outcomes for the same payer and drug combination

Appeal Tracking

All appeals are tracked through their full lifecycle within the same centralized dashboard used for initial PA submissions. Tracked appeal states include:

• Appeal Submitted
• Under Payer Review
• Peer-to-Peer Scheduled / Completed
• Overturned (Approved)
• Upheld (Denied)
• External Review Requested

Proactive Reauthorizations

Many approved prior authorizations carry expiration dates, after which the patient’s medication coverage lapses unless a reauthorization is submitted. ParaHealth monitors all active authorizations and manages the reauthorization process to prevent gaps in therapy.

Expiration Monitoring

ParaHealth continuously tracks authorization expiration dates across all active patients and triggers a multi-stage alert sequence:

When a reauthorization is triggered, ParaHealth pulls the latest clinical data from connected sources and pre-fills the submission:

• Updates lab values, vitals, and clinical notes from EHR
• Refreshes medication history and adherence data
• Carries forward previously approved clinical justification, updated with current evidence
• Flags any changes in payer policy or formulary status since the original authorization

Escalation Queue

Not every prior authorization can be fully automated. ParaHealth’s escalation queue ensures that cases requiring human judgment — clinical, administrative, or operational — are routed to the right person at the right time with full context.

Escalation Triggers

Cases are automatically escalated to the queue when any of the following conditions are met:

• AI confidence score falls below the configurable threshold
• Required clinical data is missing from available records
• Payer requests additional information after submission
• A denial is received and requires clinical review before appeal
• Drug interaction or contraindication flag is raised during processing
• Urgent or time-sensitive authorization is detected (e.g., patient in acute care)

Routing & Assignment

Escalated cases are routed based on configurable rules:

• Role-based routing — Clinical questions route to pharmacists or physicians; administrative issues route to PA coordinators
• Load balancing — Cases are distributed evenly across available staff within each role
• Priority scoring — Urgent cases (patient waiting, medication lapse imminent) surface at the top of the queue
• Manual reassignment — Staff can reassign cases to colleagues or escalate to supervisors

Escalation Context

Each escalated case includes complete context so the reviewer can act without re-researching:

• Summary of what the system attempted and where it stopped
• The specific reason for escalation
• All gathered clinical evidence and AI-generated draft answers
• Payer requirements and policy references
• Recommended next steps

Task Lifecycle Tracking

Every prior authorization — from initial intake through final determination — is tracked as a task with a defined lifecycle. Task lifecycle tracking gives staff and managers full visibility into where each PA stands, who is responsible, and what actions are needed next.

Task States

Each PA moves through a structured sequence of states:

Assignment & Ownership

Every task has a clear owner at each stage of its lifecycle:

• Tasks are auto-assigned based on role and workload when created or escalated
• Ownership transfers are logged with timestamps and reason codes
• Staff can view their personal queue filtered by state, priority, and due date
• Unassigned or stale tasks are flagged automatically

SLA Tracking

ParaHealth tracks turnaround time against configurable SLA targets for each task state:

• Time from intake to submission
• Time from submission to payer determination
• Time spent in each intermediate state
• Alerts when a task approaches or exceeds its SLA threshold

Audit Trail

Every action taken on a task is recorded in an immutable audit log:

• State transitions with timestamps and the user or system that triggered them
• All edits to clinical answers, with before-and-after snapshots
• Submission attempts, payer responses, and follow-up actions
• Escalation events, reassignments, and reviewer notes

Analytics Dashboard

The ParaHealth analytics dashboard provides a real-time view of your organization’s prior authorization performance. Key metrics are displayed in a configurable layout with date-range filtering, payer breakdowns, and drug-category segmentation.

• Total PAs submitted, approved, denied, and pending
• Average turnaround time by payer and submission channel
• Staff productivity metrics (PAs processed per user per day)
• Cost savings compared to manual processing baseline

Approval Metrics

Approval metrics track first-pass approval rates, time to approval, and approval rates by payer, drug, and diagnosis. These metrics help identify which submissions consistently succeed and where additional effort is needed.

Denial Patterns

ParaHealth aggregates denial data to surface recurring patterns. Denial pattern analysis highlights:

• Most common denial reason codes by payer
• Drug-diagnosis combinations with elevated denial rates
• Documentation gaps that frequently lead to denials
• Seasonal or policy-change-driven denial spikes

These insights feed back into the denial risk detection engine, continuously improving first-pass approval rates over time.

AI & NLP Engine

ParaHealth’s core intelligence layer combines large language models with domain-specific clinical NLP. The engine is fine-tuned on millions of prior authorization interactions to understand payer question intent, extract relevant clinical evidence, and compose answers that align with payer expectations.

• Medical entity recognition (diagnoses, medications, procedures, lab values)
• Temporal reasoning for treatment timelines and medication history
• Payer-specific language and formatting preferences
• Confidence scoring with evidence attribution

Clinical Data Extraction

The extraction pipeline processes structured and unstructured clinical data from multiple sources:

• Structured data — ICD-10 codes, CPT codes, lab results, medication lists from EHR FHIR endpoints
• Unstructured data — Clinical notes, progress reports, and specialist referral letters parsed via NLP
• Documents — Scanned PDFs and faxed records processed through OCR with clinical entity extraction

Policy Matching

ParaHealth maintains an up-to-date index of payer coverage policies, clinical criteria documents, and formulary rules. When a PA is initiated, the system:

• Identifies the applicable coverage policy for the drug-diagnosis pair
• Extracts specific approval criteria from the policy document
• Maps patient clinical data against each criterion
• Highlights met and unmet criteria with supporting evidence

This approach ensures that submissions directly address the payer’s documented requirements, significantly improving first-pass approval rates.

AI Verification Calls

Some payer interactions still require a phone call — benefit verifications, PA status checks, and peer-to-peer scheduling often sit behind an IVR phone tree with no electronic equivalent. ParaHealth operates an AI voice agent that places those calls on your behalf and returns structured results to the dashboard.

• IVR navigation — The agent authenticates with payer phone systems and traverses multi-level phone menus without human intervention.
• Real-time transcription — Call audio is transcribed and parsed with clinical NLP, extracting coverage decisions, reference numbers, and payer-stated next steps.
• Structured dashboard updates — Verified benefits, PA determinations, and call outcomes are written back to the originating task via webhook, with a full audio recording attached for audit.
• Queue orchestration — High-volume call queues are parallelized across concurrent voice sessions so benefit verifications complete in minutes instead of hours.

HIPAA Compliance

ParaHealth is built from the ground up with HIPAA compliance as a core requirement. All protected health information (PHI) is handled in accordance with the HIPAA Privacy Rule, Security Rule, and Breach Notification Rule.

• AES-256 encryption at rest and TLS 1.2+ in transit
• Role-based access control (RBAC) with MFA enforcement
• Immutable audit logs retained for 6 years per HIPAA requirements
• Regular third-party security assessments and penetration testing

Certifications & Attestations

Beyond HIPAA, ParaHealth maintains an active compliance roadmap aligned with the frameworks enterprise healthcare buyers expect. Current status:

Security questionnaires, SOC 2 progress reports, and our current subservice organization list are available under NDA. Reach out to security@parahealth.ai to start a review.

Data Privacy

Patient data privacy is maintained through strict data isolation and retention policies:

• Tenant-level data isolation with dedicated encryption keys
• Configurable data retention periods aligned with state regulations
• De-identification capabilities for analytics and reporting
• Right-to-delete support for patient data removal requests

Patient Safety

ParaHealth incorporates multiple safeguards to ensure that automation never compromises patient safety:

• All AI-generated answers require clinician review before submission
• Drug interaction and contraindication checks during PA processing
• Escalation workflows for urgent or time-sensitive authorizations
• Transparent audit trail for every PA decision and action

EHR Systems

ParaHealth integrates with major electronic health record systems through standard FHIR R4 APIs and vendor-specific connectors. Supported EHR platforms include:

• Epic (via FHIR R4 and MyChart integration)
• Cerner / Oracle Health
• Allscripts / Veradigm
• athenahealth
• NextGen Healthcare

Payer Networks

ParaHealth connects to payer networks through multiple channels to maximize coverage:

• CoverMyMeds / Surescripts — Electronic PA network covering 75%+ of commercial payers
• Direct payer API integrations — Real-time connections to major national and regional payers
• Portal automation — Secure browser-based submission for payers without electronic PA support
• Fax integration — Automated fax submission and inbound parsing for legacy payer workflows

API Overview

ParaHealth exposes a RESTful API for programmatic access to PA workflows. The API supports creating PAs, submitting answers, checking status, and retrieving analytics data.

Example — submit a prior authorization request:

POST /api/v1/prior-auth
Content-Type: application/json
Authorization: Bearer <token>

{
  "patient_id": "pat_12345",
  "prescriber_npi": "1234567890",
  "medication": {
    "ndc": "00069-0150-01",
    "name": "Eliquis 5mg",
    "quantity": 60,
    "days_supply": 30
  },
  "diagnosis_codes": ["I48.91"],
  "urgency": "standard"
}

Example response:

{
  "pa_id": "pa_98765",
  "status": "submitted",
  "channel": "epa",
  "payer": "Aetna",
  "submitted_at": "2026-03-15T14:32:00Z",
  "estimated_response": "2026-03-16T14:32:00Z",
  "questions_answered": 8,
  "confidence_score": 0.94
}