Employee Experience · Healthcare Prior Auth · ~6 min

The human side of prior authorisation.

An AI prior-auth engine recommends DENY at 88% confidence in 12 seconds. A clinical reviewer decides whether to uphold or override. The question for the CMO: can the organisation prove the human was qualified?

Persona · Carlos Vega — Clinical AI Reviewer, Vitara Healthcare Systems · HRI 72 Intermediate

Back to demos

Use case	Chief Medical Officer managing AI-assisted prior authorisation team — measuring, monitoring, and evidencing clinical reviewer qualification across the full team
Audience	CMO, CEO, Chief Compliance Officer, General Counsel, CMS / state insurance regulator preparation
Structure	Part 1: Context · Part 2: Without AITR (the gap) · Part 3: With AITR (the fix) · Closing
Persona	Dr. Pradeep Sharma — Chief Medical Officer, Vitara Healthcare Systems
Team	13-member clinical review team · avg HRI 58.8 · Developing · Risk capability gap 55.8
Frameworks	CMS-0057-F · 21st Century Cures Act · FDA AI/ML SaMD guidance · ISO 42001 cl.8.4 · NIST AI RMF · HIPAA

Part 1 · Context

Prior-auth engine in action

PA-2291 · Lumbar MRI · DENY · 88% confidence.

An AI prior-auth engine assesses the request in 12 seconds. Chronic low back pain, six months conservative therapy, no documented neurological deficit. The AI recommends denial.

A clinical reviewer now has to decide: uphold the AI, or override it.

The question: when your AI denies a patient's care request, can you prove the human who upheld it was qualified to do so? Most healthcare organisations cannot answer it.

fydelitics.ai

Prior Authorisation Engine

PA-2291 · MRI lumbar spine (CPT 72148)

DENY

Confidence

88%

Time to assess

12s

CMS window

72h

AI clinical assessment

Patient M.R., 54, chronic LBP. 6 months conservative therapy (PT, NSAIDs, chiropractic). Clinical criteria under payer policy CP-ORT-014 require documented neurological deficit (radiculopathy, motor weakness, bowel/bladder dysfunction). No deficit documented.

Recommendation

DENY · clinical criteria not met. Exception pathway available if neurological deficit is documented.

Reviewer decision required · Carlos Vega · Clinical AI Reviewer

Part 2 · Without Fydelitics.ai

2-3 · Uphold with no clinical reasoning

'Denial upheld by Carlos Vega, 11:14.'

Carlos upholds the denial. The case is closed in under three minutes.

There is no documentation of whether he reviewed the physician's functional impairment notes, whether he considered the exception pathway, or whether his decision was consistent with CMS-0057-F.

fydelitics.ai

Action Log — PA-2291

DENIAL UPHELD

ActionUphold AI denial

ReviewerCarlos Vega

Clinical reasoning—

Exception pathway reviewed—

Framework reference—

HRI / qualification—

Navigator query—

Audit trail incomplete — no qualification record on file

2-4 · The patient appeals

The organisation cannot defend.

The patient appeals. Under state law, an external clinical review is required. The reviewer asks for documentation of the clinical criteria applied and confirmation the human was qualified.

The organisation has a name and a timestamp. That is not sufficient.

fydelitics.ai

Patient Appeal — external review

External reviewer question

"Provide documentation of the clinical criteria applied by the human reviewer in upholding this AI-generated denial, and confirmation that the reviewer was qualified to evaluate it under CMS-0057-F."

Response field

— blank —

Supporting documentation: none

2-5 · Three failure modes

Patient harm. Audit exposure. Legal risk.

A clinically incorrect uphold. An undocumented override. Regulatory and legal exposure.

Each one has real patient and financial consequences.

fydelitics.ai

Clinically incorrect uphold

Reviewer upholds AI denial without evaluating physician notes flagging early neurological involvement. Patient delayed or denied necessary care.

Undocumented override

Reviewer approves despite AI denial with no documented clinical basis. Payer audit finds inconsistency.

Regulatory & legal exposure

Organisation cannot demonstrate qualified human oversight under CMS-0057-F. State regulator finding, plaintiff discovery.

The AI produced a denial. The human upheld it.
If the patient is harmed, the organisation cannot show why that was right.

Part 3 · With Fydelitics.ai

3-1 · HRI profile — before the case

HRI 72 · Intermediate · Clinical AI Review qualified.

Carlos has a readiness profile. Three courses complete, including the Clinical AI Review specialisation with a Prior Authorisation track.

The platform knows he is qualified — and by how much.

fydelitics.ai

AI Decision Readiness

Carlos Vega · Clinical AI Reviewer

Vitara Healthcare Systems · Prior Authorisation track

HRI

Intermediate

3 courses complete

Last Navigator: 10 May 2026

Oversight

Operations

Risk

NIST AI RMF

73.4

ISO 42001

70.6

OECD AI

3-2 · HRI badge surfaced in the PA queue

Qualification — and a recommended escalation pathway.

Same case. Now Carlos's qualification is surfaced in context. HRI 72 · Intermediate.

The platform also flags something important: for cases with complex neurological presentation, his Intermediate band means escalation to a physician reviewer is recommended. The system working exactly as it should.

fydelitics.ai

PA Queue · PA-2291

DENY recommended

M.R., 54 · Lumbar MRI · LBP

No formal neurological deficit · functional impairment noted

88%

Carlos Vega · HRI 72 · IntermediateClinical AI Review qualified

Note: Intermediate qualification — escalation pathway recommended for complex neurological cases.

For borderline neurological presentations, escalation to physician reviewer is recommended under ISO 42001 cl.8.4.

3-4 · Navigator — clinical & regulatory, personalised

Six steps. CMS-0057-F. ISO 42001 cl.8.4.

The Navigator does not just cite the framework — it applies Carlos's specific HRI to the decision.

Step 5: at Intermediate level, for a borderline neurological presentation, the organisation's clinical AI governance policy recommends escalation to a physician reviewer.

fydelitics.ai

AI Decision Navigator

HRI 72 · Intermediate

"AI PA engine recommends DENY for lumbar MRI. Patient: chronic LBP, 6 months failed conservative therapy, functional impairment noted but no formal neurological deficit. Confidence 88%. What are my obligations before I uphold or override?"

Based on your Clinical AI Reviewer role and Prior Authorisation Intermediate qualification:

1Under CMS-0057-F you must independently evaluate the full clinical record — not solely the AI's interpretation. The physician's functional impairment notes must be explicitly addressed.
2Functional impairment without formal neurological deficit may qualify for an exception pathway under CP-ORT-014. Review exception criteria before upholding.
3If you uphold: document the clinical criteria applied, why functional impairment alone did not meet the exception threshold, and that you reviewed the physician's notes.
4If you override: document the clinical basis, your qualifications to make that determination, and whether the case should be escalated to a physician reviewer.
5At HRI Intermediate: this case involves borderline neurological presentation. ISO 42001 cl.8.4 and your clinical AI governance policy recommend escalation to a physician reviewer.
6Regardless of outcome: your decision record must satisfy CMS-0057-F adverse determination requirements — clinical criteria, reviewer qualifications, appeal rights.

CMS-0057-FISO 42001 cl.8.4Fydelitics.ai scenarios

3-5 · Carlos escalates — with documented reasoning

The system working at the right level.

Carlos escalates. Not because he cannot make the call — but because his Intermediate qualification, the borderline neurological presentation, and the organisation's governance policy all point to escalation.

And he has documented all of it. Clinical reasoning, framework applied, qualification level, escalation pathway.

fydelitics.ai

Action Log — PA-2291

ESCALATED · evidenced

Escalation rationale

Reviewed AI denial (88%, CP-ORT-014 neurological deficit requirement). Referring physician notes functional impairment — not formally documented as neurological deficit. Exception pathway eligibility: borderline. Per Navigator recommendation at HRI Intermediate level and ISO 42001 cl.8.4, escalating to physician reviewer for final determination. Clinical complexity exceeds my qualification threshold for this presentation type. Escalation documented per CMS-0057-F.

ReviewerCarlos Vega · HRI 72 · Intermediate

FrameworkCMS-0057-F · ISO 42001 cl.8.4

Navigator querynav-q-2291-c

OutcomeEscalated to physician reviewer

3-6 · The patient appeal — now answerable

Evidence pack attached.

Same appeal. Same question. This time the evidence pack is complete before the appeal is filed.

Not only was Carlos qualified — the platform can show how qualified, what framework he applied, why he escalated, and that the escalation itself was the correct governance response.

fydelitics.ai

Patient Appeal — external review

External reviewer question

"Provide documentation of the clinical criteria applied and confirmation that the reviewer was qualified to evaluate this AI-recommended denial under CMS-0057-F."

Fydelitics_Evidence_Carlos_Vega_PA2291.pdf

HRI 72 Intermediate · escalated per ISO 42001 cl.8.4 · CMS-0057-F compliant

Clinical reasoning

Navigator query log

Escalation pathway

Framework citations

Side by Side

3-7 · Side by side

Same reviewer. Same AI. Same case.

One outcome that cannot be defended. One that can.

fydelitics.ai

Without Fydelitics.ai

With Fydelitics.ai

Reviewer evaluates AI PA recommendation with no readiness record on file.

Reviewer's HRI 72 · Intermediate · Clinical AI Review qualified is verified before review begins.

No structured framework applied. Reviewer acts on clinical instinct.

Decision Navigator surfaces CMS-0057-F obligations and ISO 42001 cl.8.4 escalation criteria.

Uphold logged as a name and timestamp. No clinical reasoning.

Decision logged with rationale, exception-pathway analysis, escalation route and framework citations.

Patient appeals: organisation cannot show clinical criteria applied.

Patient appeals: complete evidence pack — reviewer qualification, framework applied, escalation governance.

CMS-0057-F documentation requirements not fully met.

All CMS-0057-F documentation requirements met — clinical criteria, reviewer qualification, appeal rights.

Clinical liability and regulatory exposure if patient is harmed by delay.

Defensible record exists. Qualified human oversight demonstrated at every step.

Closing

4-1 · The three products

The human readiness layer that makes AI-assisted prior auth defensible.

Capability Builder to certify the clinical reviewer before they review.

Readiness Control Plane to measure qualification continuously across the clinical review team.

Decision Navigator to ground every uphold, override and escalation in the right clinical and regulatory framework.

fydelitics.ai

Fydelitics.ai

Human readiness layer

Prior Auth

AI engine

Capability Builder

Certify the clinical reviewer before they act

Readiness Control Plane

Measure qualification across the team

Decision Navigator

Ground every PA decision in CMS-0057-F