95%
of complete prior auth requests processed end-to-end in under 60 seconds in production workflows.
AI Admin Agents for Health Plans
AI Automation for Health Plans Intake, Eligibility, Claims, Prior Auth, Appeals and more
Production impact
60%
reduction in manual review workload in production deployments, while nurses and medical directors stay in control of exceptions and adverse determinations.
Health Plan Operations
AI automation that helps plans augment, not replace existing vendors and teams.
01
Works in the current stack
System-agnostic AI browser agents and APIs operate the same tools your teams use today, without requiring every vendor to build new integrations first.
02
Connects the dots
Move data and actions across intake, eligibility, prior auth, claims, denials, appeals, and reporting so teams are not stuck swivel-chairing across systems.
03
CMS-ready by design
Turnaround clocks, specific reasons, notice support, and audit trails are generated inside the workflow instead of being layered on after the fact.
Why we're different
AI automation,
existing-vendor augmentation.
GenHealth is designed to augment - not replace - the health plan's existing technology ecosystem. Our primary method of interaction is through AI browser agents and APIs that operate those systems the same way a trained human employee would, then transition to deeper integrations where APIs are available.
- Works with current UM, claims, portal, and interoperability vendors
- No need to wait for vendor cooperation to get started
- Browser-agent now, API and FHIR where available later
- One audit trail across intake, eligibility, prior auth, denials, and appeals
End-to-end workflows
Across intake, eligibility, prior auth,
denials, appeals, and retro review.
GenHealth connects the full request-to-determination process. Intake and triage agents validate completeness before routing, nurses receive structured summaries with citations, and medical directors get denial rationale and peer-to-peer prep without starting from scratch.
Policy-as-code engine
Automated policy digitization with
version control and audit trails.
Use our library or bring your own policies, criteria, and reviewer guidance. GenHealth turns medical policies into computable rules and FHIR questionnaires so updates flow into operations without manual rewrite cycles or disconnected reference documents.
Explore policy databaseSafety-first design
Near-real-time where it's safe.
Human review where it matters.
We bias toward pends, not auto-denials. Plans can configure automation thresholds for what gets auto-approved versus escalated, helping teams move toward near-real-time adjudication for high-volume services while preserving oversight on borderline and adverse cases.
Workflow coverage
Full workflow support
for health plan operations.
Intake & triage
Ingest fax, portal uploads, FHIR requests, email, and document bundles. Validate completeness before cases ever reach nurse or medical director review.
Fax · Portal · FHIR · Docs
Eligibility & benefits
Pull member, line-of-business, benefit, and prior-case context across existing plan systems and connected vendors before downstream work begins.
Member · LOB · Benefits
Prior auth & medical necessity
Identify the right policy, answer each criterion with citations, and separate clean approvals from the cases that need licensed human review.
PA · UM · Criteria
Claims, denials & appeals
Connect claims edits, denial rationale drafting, notice generation, retro review, and appeal defensibility in one audit-ready record.
Claims · Denials · Appeals
Policy-as-code
Turn medical policies into computable rules and FHIR questionnaires with full version control, audit trails, and faster updates across the program.
Rules · FHIR · Audit
Existing vendor stack
Operate across UM platforms, claims systems, portals, guidelines, EHRs, and fax without waiting for every vendor to expose perfect APIs.
System-agnostic · API + agents
60%
reduction in manual review workload from payer-side automation deployments.
72h
urgent and 7-day standard clocks tracked against CMS prior authorization requirements.
80%
near-real-time target supported through phased automation of high-volume service categories.