Healthcare & Life Sciences

Payer claims & prior authorisation

Payer operations on a unified ontology. Claims, benefits, authorisations, and care gaps from your core-admin platform — unified into one object graph. Routine work resolves autonomously with a clause-level audit trail; complex cases route to the nurse with the full reasoning chain pre-assembled.

After

Minutes – hours

PA cycle time on auto-approved cases

Before2–14 days

Inside CMS clocks (72h expedited / 7d standard, effective 2026)

After

~60–70%

Cases auto-approved within authority

Before~25–40%

Approve-only; CMS rule requires same-specialty MD on every denial

After

+30–50%

Nurse reviewer throughput on the remaining queue

Before1×

Time moves to ambiguous clinicals — not chart assembly

FacetsQNXTClinicalPBMProvider dir.Unified ontologyAgents + apps

Ontology explorer

One member, every linked object

Member (6)

Members (6)

Member object

M-2847291 · 52F · Commercial PPO

Facets

Benefit plan(1)

Choice PPO 2026Facets

PLAN-PPO-2026 · Commercial

Authorizations(1)

Agent reasoning trace

1
Policy lookup
Retrieved plan medical policy MP-2417 — Neuroimaging for adult headache. Cross-referenced InterQual CP: Imaging set (2026 update).
2
Criteria check
Approval requires one or more SNNOOP10 red-flag features for advanced neuroimaging in non-acute headache. Scanning chart and ED documentation…
3
Red-flag found
"Thunderclap onset, peak intensity <60 seconds" — documented in 2026-03-04 ED note by Dr. Aparna Iyer.
4
Comparable precedent
Three prior approvals in last 90 days on same policy clause with similar clinical pattern. False-positive rate on this clause: 1.2%.
5
Decision drafted
APPROVE — MRI brain w/o contrast (CPT 70551). Approval valid 30 days. Audit trail attached: 4 clauses cited, 1 chart note quoted, 3 precedents linked.

Claims(2)

CT head w/o contrastFacets

CLM-2026-88142 · CPT 70450 · ICD R51.9

paid

ED visit, level 4Facets

CLM-2026-88210 · CPT 99284 · ICD R51.9

paid

Care gaps (HEDIS)(1)

CBP — Controlling High Blood PressureClinical

GAP-CBP-2847 · open

Providers(2)

Neurology groupProvider dir.

PRV-4821 · Neurology · NPI ●●●●●4821

Bayview EDProvider dir.

PRV-1190 · Emergency medicine · NPI ●●●●●1190

Sourced from

FacetsClinicalProvider dir.

7 linked objects · last sync 4m ago · RLS · 10-yr audit retention.

Agent proposals · M-2847291

Actions the agent proposes on this member's objects. Each writes back to its source system. Approve / Override / Escalate stays with the reviewer.

Auto-approve PA-104821 — MRI brain w/o contrast
SNNOOP10 red-flag criterion met (thunderclap onset, documented ED note). Within approval authority.
write back toFacets
Close care gap GAP-CBP — Controlling High Blood Pressure
Recent BP reading 128/78 in clinical feed satisfies the measure. Flag for HEDIS submission.
write back toClinical

Guardrails before guardrails come up

Never auto-denies

CMS 2024 Final Rule requires same-specialty MD review on every Medicare Advantage denial. The agent approves within authority or escalates — full stop.

Cites or doesn't claim

Every clinical assertion links to the chart excerpt and the policy clause that supports it. Hallucinated citations burn nurse trust permanently; we don't ship them.

Writes back to your platform

Decisions and routing post back to TriZetto Facets / QNXT through the same object graph the agent read from. Nothing lives in a side database.

Want this on your TriZetto estate?

We'll scope a 2-week discovery sprint against one PA category on your Facets or QNXT data — and come back with the pod, the KPI, and the price.

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