AuthMatch AI

Prior-authorization copilot that matches each case to Medicare coverage policy and shows reviewers which criteria are met.

The problem

Insurance prior authorizations are slow because reviewers have to find the controlling Medicare policy for every case by hand. New CMS rules (CMS-0057-F, effective January 2026) put hard deadlines on that work: seven days for standard requests, 72 hours for expedited ones.

What it does

AuthMatch matches each case, by HCPCS/CPT code and member state, to the controlling NCD or LCD policy and reads the clinical documentation against it. The reviewer sees each criterion marked Met, Not Met, or Indeterminate with the supporting evidence cited. A licensed human reviewer signs off on every case.

Architecture

The Next.js reviewer UI is a thin shell that never touches PHI. All PHI processing, OCR, guideline matching, and LLM calls live in a FastAPI service. Postgres enforces row-level security, and an audit trigger logs every access. The design goal was strict PHI isolation and a defensible audit trail.