Prior authorization denials increasingly rely on AI. InferTrust™ binds each decision to active medical policy rules and creates cryptographic proof for member a
AI-assisted prior authorization is under increasing regulatory scrutiny. InferTrust™ Payer addresses this directly. CMS has proposed rules requiring transparency in AI-driven coverage determinations. State legislatures are considering bills mandating disclosure of AI involvement in PA decisions. In this environment, health plans and PBMs need more than assertions that their AI follows policy.
For every AI-assisted prior authorization determination, InferTrust™ captures the model and version that evaluated the request, the clinical policy and criteria applied, the resulting decision action (PA_APPROVE, PA_DENY, PA_PARTIAL, or PA_ESCALATE), the confidence score and threshold that triggered the action, and the complete chain of downstream events including peer review and appeals.
When a member appeals a denied prior authorization, the plan must demonstrate that the denial was based on established clinical criteria applied consistently. InferTrust™'s records provide cryptographic proof that the specific policy version was active, that the model applied the correct criteria, and that the determination followed the configured workflow. This evidence strengthens the plan's position in internal appeals and external reviews.
As CMS and state regulators formalize requirements for AI transparency in coverage determinations, organizations with InferTrust™ already have the infrastructure in place to produce verifiable evidence of how AI contributed to each decision. This is a strategic advantage: the cost of implementing decision integrity before regulation takes effect is far lower than retrofitting after enforcement begins.