Converus maps payer policies into structured intelligence, then uses it to handle prior authorization end-to-end, from clinical data extraction to submission and appeal.
Specialized AI agents that work across the full prior authorization lifecycle, each built on a shared intelligence layer that understands what every payer actually requires.
Your team shouldn't be pulling charts, matching criteria, and assembling cases manually. Converus pulls clinical data from your EHR, matches it against payer requirements, detects gaps, builds a medical necessity case, and submits autonomously.
Payer requirements shift constantly. New coverage criteria, updated LCDs, revised formulary rules. Converus continuously monitors and structures every policy into queryable logic so you always know exactly what's required before you submit.
68% of denials are overturned on appeal, but most teams lack the bandwidth. Converus identifies the denial reason, maps it against policy and evidence, and generates a targeted appeal with the specific documentation needed to overturn it.
Every agent is powered by a shared intelligence layer that ingests, structures, cross-references, and continuously learns from payer policies and submission outcomes.
Payer policy PDFs, LCD/NCD coverage determinations, CMS rules, state gold card laws, and regulatory mandates.
Parses documents into requirement trees with conditional branching, down to the drug, indication, payer, and line of therapy.
Maps intersections between policies, LCDs, state mandates, and federal rules so nothing gets missed.
Every submission outcome feeds back in. Tracks the gap between what payers say and what they enforce.
Because Converus understands the requirements, it can handle the entire PA workflow autonomously.
Pulls both structured and unstructured clinical data from your EHR, lab systems, and clinical documents via FHIR APIs, direct integrations, and agentic extraction techniques that can navigate portals and parse freetext notes. No manual chart review.
Identifies the exact requirement tree for this drug, indication, payer, and line of therapy. Cross-references against LCDs, NCDs, and mandates.
Compares available clinical data against every requirement. Missing a molecular test result? The system flags it with severity and either retrieves it or escalates to the care team.
Assembles clinical evidence, pulls peer-reviewed literature from PubMed and ASCO guidelines, and generates a medical necessity argument tailored to the payer's specific criteria.
Every submission gets an approval probability score. High-confidence cases auto-submit. Edge cases get flagged for your team to review. Denials trigger automatic appeal generation.
We work with your team to find the revenue leaks, implement fast, and keep improving.
Identify revenue leaks, denial patterns, and high-impact PA opportunities
Personalized to your payers, contracts, and clinical workflows
Sits on top of your existing EHR, labs, and clearinghouses
Consistent touchpoints to optimize performance from data and your feedback
Most PA requests resolve without manual intervention.
Authorization cycle time drops from days to hours.
Denials prevented at the source by understanding every requirement.
PA software at a $33B diagnostics company. Products shipped at multiple unicorn-trajectory companies. Years inside the PA process at leading laboratories. We built Converus because prior auth is a knowledge problem, and no existing tool solves it at the intelligence layer.
No. Converus plugs into your existing stack via FHIR APIs. Your workflows stay the same.
Most PA tools automate the form-filling. Converus understands the clinical reasoning behind authorizations. Our knowledge graph maps the relationship between clinical evidence, payer policies, LCDs, NCDs, and regulatory mandates to predict and prevent denials.
Every submission gets an approval probability score. High-confidence cases move through automatically. Edge cases get flagged with full context. The human-in-the-loop threshold is configurable.
We're focused on genetic testing labs, diagnostics companies, and oncology practices, where PA complexity and denial rates are highest. The architecture expands across specialties as the knowledge graph grows.
Walk through a live demo with a real PA scenario. We'll show you how the intelligence layer maps your payer mix and how the autopilot handles submissions end-to-end.
30-minute walkthrough · Tailored to your payer mix and specialty