We interpret payer policies and build compliant PAs automatically.
Your team submits faster, with better documentation, and spends less time on denials.
Three ways to use Converus, depending on what you build and who you serve.
MolDX, LCD determinations, somatic-vs-germline, and panel coverage variability — all handled.
NCCN, biomarker requirements (HER2, EGFR, PD-L1, MSI/MMR), and peer-to-peer prep — all assembled.
For teams building RCM, PA, or AI products. Live payer logic via API or MCP — without maintaining it yourself.
There's a better way.
The Intelligence layer reads and interprets every payer policy — NCCN, MolDX, and 300+ commercial payers — so we know exactly what's required. The Autopilot layer uses that intelligence to build, submit, and appeal — your team reviews the work, doesn't do the work.
Because the Intelligence layer already understands what every payer requires, the Autopilot can act on it: pulling clinical data from your EHR, matching against payer criteria, detecting gaps, building a medical necessity case, and submitting autonomously. Denials trigger immediate appeal generation.
The Intelligence layer continuously ingests and structures payer policies, LCDs/NCDs, NCCN guidelines, MolDX determinations, and state mandates into a queryable knowledge graph. Every case submission draws from the same living source of truth — one that learns from every outcome.
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.
The Intelligence layer is what makes clinical reasoning possible at scale. It ingests payer policies, NCCN guidelines, MolDX determinations, LCDs/NCDs, and submission outcomes — and continuously structures them into the logic the Autopilot runs on.
NCCN, MolDX, LCD/NCD determinations, somatic-vs-germline distinctions, panel coverage, and biomarker-level payer criteria — all structured, not scraped.
Clinical evidence assembly, not form-filling. The system builds the medical necessity argument from the evidence, matched to what this payer actually enforces.
Every submission outcome feeds back in. The knowledge graph tracks the gap between what payers say in policy and what they approve in practice.
Maps intersections between policies, LCDs, state mandates, and federal rules. Nothing gets missed because requirements live in silos.
Because the Intelligence layer already understands the requirements, the Autopilot can handle the entire PA workflow without manual intervention — from chart review to submission to appeal.
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.
From first call to first submission. No rip-and-replace, no long implementation cycles.
We'll show you how Intelligence + Autopilot work with your actual test catalog and payer mix. ~30 min
We integrate with your LIS, EMR, or intake process — no rip-and-replace required. 1–2 weeks
Choose Done For You, Done With You, or Intelligence Only — and start reducing your PA burden. Immediate
Pick the engagement that fits your team. Same platform — different levels of Converus involvement.
You submit cases, we return completed PAs ready for your review and submission. Best for labs that want minimal staff involvement in PA workflows.
We build the PAs and prep the submissions, your team reviews and approves. Best for labs that want oversight but need speed and accuracy.
Access our Intelligence layer to build your own PAs faster. Best for labs with existing PA teams who want better policy guidance and tools.
Three forces are converging — and the labs that adapt this year will be the ones that keep their margins.
UHC, Cigna, Aetna, and other major payers have rolled out stricter PA criteria this year. Labs using outdated templates are seeing more auto-denials — and the bulletins keep coming.
Commercial payers have added 40% more documentation requirements year-over-year. Each new requirement is one more place a PA can fail without the right intelligence layer.
Industry-wide RCM staffing is in crisis. You can't hire your way out of this problem — the talent pool isn't growing fast enough, and the people you have are leaving for less stressful work.
Every denied PA delays revenue by 3–6 weeks on average. For high-volume labs, that's working capital tied up in administrative friction — money that should be reinvested in your test catalog and your team.
We don't just read policies — we interpret them. Mapping NCCN guidelines to payer coverage, tracking MolDX LCD/LCA updates in real time, and knowing when federal or state law overrides payer policy.
Built for genetic testing, not generic healthcare. Pre-loaded test catalog templates, multi-gene panel documentation logic, and workflows for pharmacogenomics, tumor profiling, and hereditary cancer.
Other tools give you information. We do the work. Not just a policy lookup. Not just a form-filler. End-to-end automation from submission through appeals.
Embed domain intelligence into your product so your automations stay accurate as policies, payer behavior, and workflow logic change.
Most RCM automations break when payer rules change, policies get updated mid-quarter, or coverage criteria shift. Converus provides the intelligence layer — via API or MCP — that keeps your product current. Power any RCM workflow that touches payer policy without constantly rewriting rules by hand.
Plug Converus intelligence into your existing RCM platform, workflow engine, or AI product. Access live payer logic without building and maintaining it yourself.
Payer requirements structured into queryable logic and updated as policies change — LCDs, NCDs, NCCN guidelines, commercial payer mandates.
Not just generic rules — specific coverage criteria for genetic testing, oncology drugs, diagnostics, and specialty workflows.
Understand why cases fail and what evidence drives successful appeals — structured for automation.
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.
Most labs complete integration and setup within 2 weeks. Demo to launch typically takes 3–4 weeks.
We cover NCCN, MolDX, and 300+ commercial payers. If we don't have your payer, we'll build it custom as part of onboarding.
No. We adapt to how you work — whether that's full automation (Done For You), collaborative review (Done With You), or DIY with better tools (Intelligence Only).
Our Intelligence layer updates automatically. You'll get alerts when policies affecting your tests change, with the updated documentation requirements.
Pricing depends on your volume and which option you choose (Done For You, Done With You, or Intelligence Only). Book a demo and we'll create a custom proposal based on your PA volume.
We can't control payer decisions, but we can ensure every PA is built with complete, compliant documentation according to current payer policies. Our goal is to give you the best possible chance of approval on first submission.
See how Intelligence + Autopilot can transform your prior auth workflow.
Built for genetic labs and oncology practices.