HealthcareNew · Legal & Compliance
Prior authorization. Submitted, not stalled.
Assembles a complete prior authorization request from the chart — diagnosis, treatment history, and medical necessity criteria — and cites every criterion to payer policy before submission. Built for health systems and specialty practices burning staff hours on payer back-and-forth.
16 cited fields per request. Built on Sphere AI Foundry.
prior_auth — request #PA-30187LIVE
00:00Ingest → chart pull, patient T. Alvarez, CPT 72148read
00:04Medical necessity → 3/3 payer criteria matchedpassed
00:08Prior treatment → conservative therapy, 6 wks documentedpassed
00:11Payer policy → Aetna LCD L34924, imaging order gapflagged
00:14Disposition → Ready to submit, 1 gap to resolverouted
review time 11sfields cited 16/16clinician sign-off required
Organizations around the world trust us
Built on Sphere AI Foundry·HIPAA-aligned by design·21 years, 300+ clients
Manual prior auth doesn't scale with payer volume
A single prior authorization means a care coordinator pulling the chart, reading the payer's medical policy, matching diagnosis and treatment history against the criteria line by line, and writing up a submission — then doing it again for the next payer's different form. At low volume that's manageable. Across hundreds of requests a month spanning dozens of payer policies, it's the reason approvals sit in a queue for two weeks while the patient waits.
83%
faster first-pass request assembly vs. manual chart review
16
fields extracted & cited per request
100%
of medical-necessity matches traceable to a payer policy citation
Chart in, cited submission out
Four steps, every one logged and citable back to the chart and the payer policy.
01
Ingest
Reads the chart directly from your systems
Progress notes, diagnosis codes, prior treatment history, and imaging or lab results — read from your EHR or clinical documentation system. No separate upload step.
Source chart
Request PA-30187 — CPT 72148, patient T. Alvarez
02
Match against payer policy
Every criterion checked against the specific payer policy
Diagnosis, conservative-treatment history, and imaging order — each checked against the payer's current medical policy or local coverage determination, not a generic checklist.
Example query
"Has 6 weeks of conservative therapy been documented for this payer's LCD?"
03
Cite every match
No criterion match without a citation
Each matched or unmet criterion links back to the exact payer policy section and the chart note it was matched against — the citation travels with the finding, not as a separate lookup.
Cited finding
Imaging order missing from chart — required under LCD §2.1 before submission.
cited to Aetna LCD L34924 §2.104
Classify & route
One disposition, one consolidated gap list
The agent returns Ready to Submit, Ready with Gaps, or Additional Documentation Needed, with a consolidated list of unmet criteria routed to the care coordinator or clinician for sign-off before submission.
Classification
Ready to SubmitReady with Gaps ✓Additional Docs Needed
16 fields, every one cited
What the agent extracts from every request it assembles.
Disposition summary & submission readiness
Patient & payer/plan verification
Diagnosis & CPT/HCPCS code match
Medical necessity criteria, cited to policy
Conservative-treatment history documentation
Prior authorization history on the same diagnosis
Site-of-service & level-of-care check
Missing-documentation gap list
Consolidated criteria-match report
Clinician review checklist & sign-off record
Typical inputs
What the agent reads, and what it connects to.
Documents
- Progress notes and clinical documentation from the current encounter
- Diagnosis, imaging, and lab results supporting medical necessity
- Prior authorization history on the same diagnosis or treatment
- Payer medical policy or local coverage determination (LCD) in effect
- Prior denial letters or peer-to-peer review notes, where applicable
Systems
- EHR / clinical documentation system
- Payer portal or clearinghouse
- Document repository or imaging system
Is this the right fit?
Built for volume — not a one-off request.
✓ Works best for
- Health systems and specialty practices submitting 100+ prior auth requests a month
- Teams standardizing against a fixed set of payer medical policies
- Revenue cycle wanting every criterion match traceable to payer policy
Too small for
- A single urgent request a care coordinator can submit faster than configuring the match
- Replacing clinician judgment on medical necessity or the final submission decision
- Payers or plans without a published medical policy or LCD to match against
Grounded in payer policy, not a black box
Compliance-first, the same standard every Sphere agent is held to.
The agent requires the complete chart and the payer's current medical policy before it will return a disposition, and every request sits between chart review and submission — never past it. A clinician or care coordinator confirms every submission before it reaches the payer.
Findings reference the specific payer medical policy or LCD section directly, with PHI handled under the same HIPAA-aligned access controls every Sphere agent on the Foundry is held to.
Prerequisites complete chart
Complete chart documentation and the payer's current medical policy required before a disposition is returned.
Human review required
A clinician or care coordinator confirms every submission before it reaches the payer — never fully autonomous.
Regulatory grounding HIPAA-aligned
Findings reference the specific payer medical policy or LCD section directly in every request, with PHI handled under HIPAA-aligned access controls.
Foundation Sphere AI Foundry
Access controls and audit trail configured here carry forward to every other agent you deploy.
Frequently asked
Does the Prior Authorization Accelerator decide whether a request is approved?
No. It assembles the request and cites every medical-necessity match for a clinician or care coordinator to review — the payer still makes the coverage decision. Nothing is submitted without that sign-off.
What types of prior authorization does it support?
Radiology and imaging, durable medical equipment, specialty pharmacy, and elective procedures out of the box. Additional service lines can be added during onboarding with the relevant payer policies configured in.
How does it integrate with our EHR?
It reads directly from your EHR, clinical documentation system, or payer portal — no separate upload step required. Integration scope is confirmed during deployment planning.
Is every criterion match traceable to payer policy?
Yes. Every matched or unmet criterion cites the specific payer policy or LCD section it came from — there is no finding without a citation back to the source.
How is this different from a generic prior-auth software tool?
It's built specifically around matching a chart against payer medical-necessity criteria, not a general eligibility or scheduling tool. It runs on Sphere AI Foundry, so the access controls and audit trail configured here carry forward to other agents you deploy.
Hear from
our clientsHear from our clients
Lee Ebreo
VP of Engineering at Credit Ninja
These things would not have been achievable if we did not build our own in-house system and if we did not partner with Sphere to help us achieve our goals.
Selah Ben-Haim
VP of Engineering at Prominence Advisors
Our experience with Sphere and their team has been and continues to be fantastic. We keep throwing new projects at them, and they keep knocking them out of the park (including the rescue of a project that was previously bungled by another vendor).
Ben Crawford
Senior Product Manager at Enova Financial
I would expect to be delighted. It's been a really positive experience, working with Sphere, and I would expect you to have the same.
Mark Friedgan
CEO at CreditNinja
Sphere consistently prioritizes the needs of their clients, demonstrating both agility and teamwork. As an offshore team, they have been an integral part of our organization and we plan to continue growing with them.
René Pfitzner
Co-Founder at Experify
Sphere provided excellent full-stack development manpower to augment our team and help push our product forward. They are easy to work with, tech-savvy and proactive.
Bruce Burdick
Chief Information Officer at Integra Credit
We've been working with Sphere and its excellent consultants since our founding. I've found that they are true partners in the success of our business.
Jemal Swoboda
CEO at Dabble
The resources and developers that Sphere Software provides are skilled and have the required technical expertise, but more importantly, they have helped us build a culture of excellence within our team.
Arthur Tretyak
Founder and CEO at IntegraCredit
With Sphere, we were able to migrate in half the time it would take to train an additional FTE… and for a fraction of the cost. Our experience with Sphere has been exceptional.
Lee Ebreo
VP of Engineering at Credit Ninja
These things would not have been achievable if we did not build our own in-house system and if we did not partner with Sphere to help us achieve our goals.
Selah Ben-Haim
VP of Engineering at Prominence Advisors
Our experience with Sphere and their team has been and continues to be fantastic. We keep throwing new projects at them, and they keep knocking them out of the park (including the rescue of a project that was previously bungled by another vendor).
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Start here
See it on your own charts
Bring three real prior authorization cases to the demo. We'll show the request assembly live — criteria match, citations, and the gap list, on your own charts.
Looking for a different workflow? Browse the full Agent Catalog.
Talk to a solutions architect
Direct to a senior architect — never a sales queue. Replies within one business day.
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