Automate Prior Authorization Submissions with a Custom AI Agent

Most small dental and vision practices rely on their Practice Management System (PMS), like Dentrix or Eaglesoft, for daily operations. For submissions, they might use a clearinghouse like Availity. These systems are excellent for processing standard electronic claims using the ANSI X12 278 transaction format. However, they fail when a payer does not accept this standard for a specific procedure, which is common for crowns, implants, or complex vision care.

Consider a treatment coordinator at a 10-person dental practice submitting a prior authorization for a three-unit bridge. She opens the patient's chart in Dentrix, then opens a browser tab for the MetLife provider portal. She manually copies the patient’s name, date of birth, and member ID from the PMS to the portal form. The portal requires a clinical justification, so she must read the dentist's notes, summarize them into a narrative, and upload the correct X-ray images. This entire manual process takes 15 minutes per patient, repeated dozens of times daily.

The structural problem is that a PMS and clearinghouse are built for structured data exchange, not dynamic web interaction. They are fundamentally databases with EDI endpoints. They have no built-in capability to log into a website, navigate a custom user interface, or interpret the unstructured text of a dentist's notes. This forces your most experienced staff into time-consuming, repetitive data entry work that is prone to human error, leading to submission delays and potential denials.

The first step would be a focused audit of your highest-volume payers. Syntora would work with you to identify the top 5-10 insurance portals that create the most manual work. You would provide temporary, read-only access to these portals in a test environment. Syntora then maps every field, button, and document upload workflow for the procedures you submit most often. This audit results in a clear automation plan you approve before any code is written.

The technical approach uses HIPAA-eligible AWS services. A Python script running on AWS Lambda uses the Playwright library to drive a headless web browser, precisely replicating the manual steps your staff takes. To handle clinical narratives, the Claude 3 Sonnet API reads unstructured text from your patient records, extracts the relevant details, and composes a justification that meets payer requirements. Every submission, including the confirmation number from the portal, is logged in a Supabase database to create a complete, verifiable audit trail. The system is architected for a sub-180 second processing time per authorization.

The delivered system is a simple, secure web application hosted on Vercel. Your staff selects a patient and procedure, and the agent runs the submission in the background. When the authorization is submitted, a notification is sent to your office's Microsoft Teams or Slack channel with the confirmation details. This workflow requires zero changes to your existing PMS and minimal staff training.