Prior authorization

Scenario. A prior-authorization request plus the clinical chart come in. When the request meets medical-necessity criteria cleanly (or is gold-carded), it auto-approves. Otherwise a medical director must review the chart and sign the adverse determination before it is transmitted to the provider.

Vertical: prior-auth · Parks at gate step-id: signoff (gate:medical-director-signoff).

1. Start the run

RUN=$(curl -s -X POST "$API/process-runs" \
  -H "Authorization: Bearer $TOKEN" \
  -H "Content-Type: application/json" \
  -d '{
    "vertical": "prior-auth",
    "inputs": {
      "member_id": "M-10293",
      "procedure_code": "27447",
      "diagnosis": "M17.0"
    }
  }')
RUN_ID=$(echo "$RUN" | jq -r .id)

The run pulls the chart, runs clinical and policy checks concurrently, and — when the request does not meet criteria cleanly — drafts an adverse determination and parks at the medical-director gate.

2. Read where it parked

curl -s "$API/process-runs/$RUN_ID" -H "Authorization: Bearer $TOKEN"

status is awaiting_human; the run parked at the signoff step.

3. Resume — the medical director signs

curl -s -X POST "$API/process-runs/$RUN_ID/resume" \
  -H "Authorization: Bearer $TOKEN" \
  -H "Content-Type: application/json" \
  -d '{
    "gate": "signoff",
    "decision": "denied"
  }'

decision is the director's call. The downstream gateway routes on it — a denied determination proceeds to transmit; other verdicts (e.g. requesting more information via an X12 275) route differently.

4. Outcome

After the signed determination, the run transmits it to the provider and tracks the CMS-0057-F decision SLAs. If the provider appeals, the run parks again at the appeal-review gate for a same-or-similar-specialty physician. A clean, criteria-meeting request never reaches the gate at all — it auto-approves and notifies electronically.