HCSC AI-enabled prior auth tool reduces claims submissions to 6 minutes

Health Care Service Corporation says its prior authorization tool, first developed in 2021, can streamline the submission process and provide auto-approvals when certain key criteria are met.


The prior auth tool was piloted on specialty pharmacy and behavioral health requests in 2022. This year, the tool is also used for inpatient acute care, long-term acute care, inpatient rehabilitation, skilled nursing care, outpatient and inpatient hospice care, home health and outpatient services.

Approvals once took 14 days, and are now “instantaneous,” according to a statement from the customer-owned health insurer.

HSCS also said its new artificial intelligence implementation is used for 93% of HCSC members for certain procedure codes. The algorithm references historical authorizations and claims to approve the treatments.

Of note, the company says the tools cannot deny prior authorization requests – they are approved or advanced to a hands-on review by HCSC clinicians and staff.

HCSC, which has 18 million members across Illinois, Montana, New Mexico, Oklahoma and Texas, has eliminated prior authorization requirements for nearly 1,000 procedure codes since 2018, the company said.


John Gaines, vice president of marketing at Cohere Health, discussed machine learning as a way to provide a better path for prior authorizations recently at HIMSS23 in Chicago.

The company applies ML to reduce nurses’ administrative burdens, but also to gather rich data about members and populations.

Instead of just acting like a transaction with a yes or no result for a request, the company is using request interactions as an opportunity to learn more about a patient and make proactive suggestions – or approve evidence-based services the provider hasn’t requested yet.

Staffers who spend “inordinate amounts of time” dealing with so many intricacies of a multitude of plans can “breathe a sigh of relief,” he said.


“We recognize that providers and payers need to work together to help make the healthcare process easy to use and effective to benefit our members,” said Dr. Monica Berner, HCSC chief clinical officer.

“For us, ‘fixing’ prior authorization so it works better for everyone isn’t a new idea and we’re happy to see others in the industry moving in that direction as well.”

Andrea Fox is senior editor of Healthcare IT News.
Email: [email protected]

Healthcare IT News is a HIMSS Media publication.

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