Prior authorization inside Epic runs through the Referrals and Authorizations workflow, where staff open the auth activity on an order or referral, capture what the payer requires, submit the request, and record the decision. Epic can flag when an order needs authorization and, for payers connected through electronic authorization, exchange part of that request electronically, but for many payers the submission still happens on the payer's own portal or by phone, and a person keys the authorization number and status back into Epic. An AI agent runs that same workflow by driving the same screens: it opens the auth activity, assembles the clinical detail, submits through the path the payer accepts, tracks status, and writes the result back onto the order. Because it operates the interface staff use, it does not need a custom integration, and the authorization status is current in Epic before the service happens.
How does prior authorization work in Epic?
Epic handles prior authorization inside its Referrals and Authorizations workflow. When an order or referral is placed, staff open the authorization activity, where Epic can indicate that the service requires payer authorization, and they record the payer, the CPT or service codes, and the supporting clinical information. For payers connected through Epic's electronic authorization capability, part of that request can move electronically, and the standard transaction behind an electronic prior authorization exchange is the HIPAA 278. For many payers, though, the real submission still happens on the payer's own portal or by phone, and the staff member then returns to Epic to enter the authorization number, the approved units or visits, the valid date range, and the status. So Epic gives you the tracking structure and, for some payers, an electronic path, while the hands-on submission and follow-up sit on top of it. For how AI operates across this workflow, see how AI runs inside Epic.
Can AI submit prior authorization in Epic?
Yes. An AI agent submits prior authorization by operating the same Epic screens a staff member uses, so it works without a custom build. It opens the authorization activity on the order, reads the payer and the service being requested, assembles the required clinical detail from the chart, and submits the request through the path that payer accepts. Where Epic's electronic authorization is enabled for that payer, the agent uses it; where it is not, the agent completes the payer's own portal form directly, which is the same fallback a person uses today. This matters because prior authorization is a heavy, repetitive load: practices complete an average of 39 prior authorizations per physician each week and spend about 13 hours on them, per the AMA. Running that volume consistently, and starting each request the same day the order is placed, is where an agent takes real time off the team without waiting for every payer to be wired into Epic.
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Submitting the request is only useful if the answer gets back to the record. Once the payer responds, the agent writes the outcome into Epic's authorization fields on the order: approved, denied, or pended, along with the authorization number, the units or visits approved, the valid date range, and any payer reference number. It attaches the payer's response so the detail is on the chart rather than in a separate portal. When the payer denies the request or asks for more clinical information, the agent does not guess: it flags the case with the payer's stated reason, including the CARC or RARC code where the payer returns one, and routes it to a person to work, whether that means a corrected submission, a peer-to-peer, or an appeal. Because the result lands on the order inside Epic, scheduling and billing see a current authorization status before the service is delivered, which is what prevents an authorization-related denial instead of reworking one after the claim is rejected.
Does Epic automate prior authorization on its own?
Epic provides the workflow and, through electronic authorization and its payer connections, can automate parts of the exchange for participating payers. What it does not do on its own is complete every submission across every payer, because a large share of payers require their own portal or a phone call and apply their own medical-necessity criteria that a generic order does not satisfy. The labor-intensive parts remain: assembling the specific clinical evidence the payer wants, submitting through that payer's path, chasing status until a decision comes back, and recording the result on the order. That is the gap an AI agent fills. It works inside the same Epic screens rather than a separate system, uses electronic authorization where it is available and a payer portal where it is not, and hands off the judgment calls, so the practice gets consistent submission and follow-up without replacing the Epic workflow the team already knows. For the standalone view of this capability, see prior authorization automation.
Flexbone can map which prior authorizations run cleanly through Epic's electronic authorization and which still need a payer portal or a call, then submit them, track status, and write the results back onto the order. To walk through your Epic prior authorization workflow and see what AI can run inside it, book a call with Flexbone.