Case Health AI embeds AI agents into health plan workflows to automate tasks such as utilization management, prior authorization, and care management. The platform lets payors add custom drug and procedure rules, supports both fax and electronic prior authorization, and provides a full audit trail, while an AI voice agent contacts providers for missing documentation. This streamlines intake, applies guideline‑driven medical necessity reviews, and speeds determinations using the insurer’s own policies.
Funding
Funding not disclosed
Founders
Product
Problem
Health plans and provider groups face fragmented, manual prior authorization and utilization management processes that involve multiple handoffs, faxed documents, and phone queues, leading to delays, inconsistent clinical decisions, and administrative burden.
Solution
Case Health AI embeds customizable AI agents into existing payer workflows to automate intake, case structuring, and clinical review for prior authorizations, utilization management, and care management. The platform ingests requests from fax, portals, phone, and X12 278, normalizes the data, and applies payer‑specific rules and formulary guidelines to generate review‑ready cases. An AI voice agent contacts providers to collect missing documentation, maintaining a full audit trail for compliance. Results are delivered in the format required by the health plan’s systems (FHIR, HL7, JSON, XML, etc.), enabling seamless integration without replacing legacy infrastructure.
Target Audience
Primary customers are health insurance payers and provider groups that manage prior authorizations, utilization management, and care coordination workflows.
Features
- Multi-channel data ingestion gateway supporting fax, PDF, JSON, HL7, X12 278, and unstructured formats
- Automated case creation that structures incoming prior‑auth requests into review‑ready formats
- Customizable payer rule engine for drug and procedure guidelines, including formulary compliance
- AI voice agent that contacts providers to obtain missing clinical documentation
- Full audit trail logging for regulatory compliance and traceability
- Flexible output delivery in FHIR, HL7, JSON Schema, XML, or custom schemas for easy system integration
- Continuous model training using the health plan’s historical and live data to keep AI aligned with evolving policies