What this page covers
Radiology is an authorization business with an imaging suite attached. The scan itself takes minutes; getting it approved, scheduled, and paid takes the rest. Most commercial plans delegate advanced imaging to a radiology benefit manager such as eviCore, Carelon, or HealthHelp, each with its own portal, clinical criteria, and turnaround. Miss the authorization and the study is written off after it has already occupied the scanner. Flexbone determines whether a study needs authorization, assembles the clinical documentation, submits through the right benefit manager, verifies eligibility, schedules the patient, and works the denials that come back.
How does AI handle radiology prior authorization?
Flexbone determines the requirement per modality and payer, then submits and tracks it. Advanced imaging is where the rules concentrate: MRI (70551, 72148, 73721), CT (70450, 71260, 74177), PET, and nuclear cardiology commonly require authorization, while plain film and most ultrasound do not. Which benefit manager applies depends on the plan, so the agent checks the member's coverage first, then routes to eviCore, Carelon, HealthHelp, or the plan directly through RadMD or the payer portal. It assembles what the clinical criteria actually ask for: the referring diagnosis, the symptom duration, and the conservative treatment already tried, which is the field most often left blank on a denied request. Each submission is tracked to a decision rather than left in a queue. The imaging and radiology PA page covers the modality rules in more detail.
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Can AI schedule imaging studies and verify eligibility?
Yes, and in radiology the two belong together because the order arrives before the patient does. Imaging volume comes from referring practices as orders, so the first contact is often an outbound call to a patient who is expecting one. Flexbone runs the 270/271 eligibility check when the order lands, books the study into the correct modality and slot length, and handles the preparation instructions each study needs: fasting for an abdominal CT, contrast and creatinine screening, implant and device screening before an MRI. It confirms the appointment, answers inbound scheduling calls around the clock, and rebooks the cancellations that otherwise leave a scanner idle. Where a plan leaves significant patient responsibility, the agent can deliver the estimate before the visit rather than after.
How does AI work radiology denials and appeals?
Flexbone reads the remittance, classifies the reason, and routes it. Radiology denials cluster in a few places: no authorization on file, authorization that does not match the study performed, medical necessity, and the technical versus professional component split that is specific to imaging. Modifier 26 and TC errors and mismatches between the ordered and performed study are common and mechanical, which makes them a good fit for automation. The agent maps the CARC and RARC codes on the remittance, corrects and resubmits the fixable ones, and assembles the clinical record for the medical necessity appeals that need a human argument. Denials that need a radiologist go to a radiologist with the documentation already gathered.
How does Flexbone deploy into a radiology operation?
We start with an audit rather than an installation. Flexbone is a forward-deployed engineering team: we sit with your operation, watch how orders actually arrive and where they stall, and instrument the workflow before automating any of it. For an imaging center that usually means measuring what share of orders arrive incomplete, how long authorization takes by benefit manager, and which denial reasons repeat. Then we build agents against your standard operating procedures rather than a generic template, running inside the RIS, PACS, and billing systems your staff already use. Voice agents cover the referring-office and patient calls, browser agents work the benefit manager portals, and everything writes back with an audit trail. Exceptions route to your team with the context attached.