Turn payer requirements into a review-ready prior authorization.
See the governing policy when it is available, flag missing evidence, prepare the decision packet, and keep approval and follow-up on one controlled path.
Synthetic case path
Approval-gated- SignalDetected at the source
Aetna tightened the step-therapy rule for infliximab.
- BriefPlain language
What changed, who it touches, and the new documentation it asks for.
- ActionPrepared for you
A prior-auth packet, built to the new criteria, ready to send.
- ApprovalAlways a person
Your coordinator reviews and approves. Nothing moves until they do.
- ReconcileNo synthetic success
The attempt stays waiting until payer evidence resolves it.
Sources stay cited. Unknown requirements stay unknown. Nothing payer-facing begins without approval.
Prior authorization is where the day goes sideways.
Requirements live in payer sites, deadlines live in spreadsheets, and follow-ups live in somebody's memory. Upstream turns that fragmented work into a sourced case, a clear decision, and an accountable next step.
From requirement to reconciliation.
One path for the source, the evidence gap, the human decision, the execution attempt, and the status that still needs attention.
- 1
Signal
A change in payer behavior or a requirement worth acting on.
- 2
Brief
Plain language: what changed and what it means for the practice.
- 3
Action
The prepared work. An appeal, a submission, a verification.
- 4
Approval
A person on your team approves before anything executes.
- 5
Reconcile
External evidence resolves the attempt and informs the next case.
Know what the case needs next.
Upstream starts with the requirement and keeps the decision context attached through submission and follow-up.
Prior authorization
Where we startEach case carries an explicit state: ready to submit, needs evidence, blocked, or unknown. Upstream shows the available source, assembles the checklist, and holds the proposed action for review.
Prior auth readiness
Sample data- Ready to submit
Infusion biologic, J3490
Aetna Auth window: 12 days
- Needs evidence
IVIG infusion, J1569
UnitedHealthcare Missing: step-therapy proof
- Blocked
Chemo administration, 96413
Cigna Auth expiring: 3 days
Benefits and eligibility
Connected eligibility checks can add current coverage context when the practice has an approved, configured rail.
Payer-policy monitoring
Available policy sources carry identifiers and effective dates so a changed requirement can be reviewed in context.
Denial management
Appeal work can retain the requirement, evidence, approval, and submission history instead of restarting from a blank form.
Revenue intelligence
Confirmed dispositions and ledger entries stay separate from estimates so operators and finance can review the same evidence.
Prior authorization is the front door. The whole case is the difference.
Plenty of tools touch prior auth. Fewer carry the entire case, in the specialties where payer friction hits hardest, while there is still time to act.
The next action stays clear
Requirements, missing evidence, the approved packet, and follow-up stay connected instead of splitting across portals and spreadsheets.
The source stays attached
When a governing policy is available, Upstream shows the source and effective date. When it is not, the case stays explicitly unknown.
The decision stays with your team
A reviewer sees the proposed action, destination, evidence posture, and unresolved gaps before approving a payer-facing step.
The attempt stays accountable
Approved work is tied to its payload, rail, owner, attempt state, and reconciliation evidence instead of disappearing into an untracked send.
Designed for high-burden procedural specialties.
The clinical details differ, but the operating discipline is consistent: source the requirement, identify the gap, review the action, record the rail, and reconcile the result.
Plain answers.
- How does Upstream handle prior authorization?
- Upstream shows the governing requirement when one is available, names what is missing, and prepares a decision packet for review. Each case stays ready, needs evidence, blocked, or unknown until the facts support the next state. A person on your team approves before a payer-facing step begins.
- What is Upstream?
- Upstream is a prior authorization operations platform for procedural specialty practices. It keeps requirement sources, case readiness, reviewer decisions, submission attempts, and follow-up connected.
- Is this another dashboard?
- No. It turns requirement and case evidence into review-ready work, then keeps the approved attempt visible until the external status is reconciled.
- How does Upstream keep our data safe?
- Upstream uses tenant-scoped access, encryption, Business Associate Agreement gating, and approval records for payer-facing execution. Our security pages describe the controls in place and the certifications we do not hold.
- Which specialties does Upstream serve?
- Upstream is designed around procedural specialty workflows with high prior-authorization burden, including infusion, oncology, rheumatology, gastroenterology, neurology, cardiology, orthopedics, and pain management.
Start with a clearer next action.
Open a workspace on the free Assist plan, or walk through a synthetic prior authorization case before you decide.