What is the prior authorization case workbench?

It is one place for the available requirement source, evidence findings, proposed action, transport posture, execution attempts, and confirmed disposition. Unknown remains a first-class state when policy or external status is unavailable.

Does Upstream file prior authorizations with payers automatically?

Not universally. A person approves every payer-facing action. A tenant can use a recently verified FHIR PAS rail where one is configured, or an assigned human-service path that requires structured submission and reconciliation evidence.

Does Upstream predict which cases will be denied?

Upstream can return a truth-labeled risk response and evidence findings. The current denial-risk service reports whether it used a promoted model or the conservative heuristic; we do not publish an accuracy claim without production evidence.

How is patient data protected in this loop?

PHI-bearing workflows use tenant-scoped access, encryption, BAA gates, and approval records. Third-party transmission remains disabled until the relevant contractual and capability checks pass.

How care intelligence works

Know what the case needs, approve the exact next step, and keep follow-up visible.

The prior authorization workbench connects available payer requirements, evidence gaps, the reviewer decision, the selected rail, and reconciliation without pretending submission is the outcome.

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What happens, from signal to outcome?

Care intelligence runs in five steps: Signal, Brief, Action, Approval, Outcome. We see what a payer changed, explain it in plain language, prepare the case it calls for, most often a prior authorization, and wait for your team to approve. The approved attempt then stays waiting, blocked, failed, unknown, or completed according to recorded evidence.

See the controlled path in thirty seconds.

A synthetic walkthrough from sourced requirement to reconciliation.

Five steps, one for your team to decide

What we carry, and where your team steps in.

Preparation can be automated. The decision remains yours, and unresolved external work remains visible.

Signal

A sourced change becomes work only when the evidence supports it.

Upstream versions available payer-policy sources and can surface a relevant change by payer and procedure. Missing source coverage remains unknown instead of becoming a guessed requirement.

Your team sees

A Signal with its payer, procedure, source identifier, and effective date when available.

Your team does

Reviews the source and decides whether the change belongs in the current queue.

Brief

We turn it into one calm, plain explanation.

The Brief explains what the available source says, which cases may be affected, and what remains uncertain. It does not turn a missing payer rule into a confident instruction.

Your team sees

A short Brief: what moved, who it affects, and the next step we recommend.

Your team does

Reads it in under a minute and decides whether to act now or keep watching.

Action

The prior authorization case arrives prepared, not as one more thing to start.

The case workbench joins the available requirement, packet fields, evidence findings, proposed action, and transport posture. It marks the case ready, needs evidence, blocked, or unknown according to the facts on hand.

Your team sees

A sourced checklist, the missing fields and evidence, the proposed destination, and the next safe action.

Your team does

Reviews it, adjusts anything, and stays in control. Nothing has left the practice yet.

Approval

Your team approves the exact action and destination.

The reviewer sees the proposed payload, evidence posture, destination, and unresolved gaps. Approval binds that content before a verified electronic rail or assigned human submission path can begin.

Your team sees

The decision packet, destination, evidence posture, and consequence of approval.

Your team does

Approves, requests a change, or holds the action. Changed content must be reviewed again.

Reconcile

The attempt stays open until external evidence resolves it.

Submission is not the outcome. Waiting, blocked, failed, and outcome-unknown attempts remain visible until a payer disposition or other structured evidence is recorded.

Your team sees

The attempt state, rail, owner, follow-up date, and the evidence needed to close it.

Your team does

Records the payer-facing disposition and keeps unresolved work assigned.

The upstream view of every case

The prior authorization case workbench is the anchor.

Available requirement sources, evidence findings, proposed actions, execution attempts, and reconciled dispositions stay connected. Unknown data and waiting attempts remain explicit.

Payer requirements

Sample data

Clinical criteriaMet
ICD-10 and CPT alignmentVerified
Functional baselinesConfirmed
Step-therapy history, 6 monthsNeeds evidence

Readiness: Needs evidence. One item open before submit.

Prior auth readiness

Sample data

Infusion biologic, J3490
Aetna Auth window: 12 days
Ready to submit
IVIG infusion, J1569
UnitedHealthcare Missing: step-therapy proof
Needs evidence
Chemo administration, 96413
Cigna Auth expiring: 3 days
Blocked

Every prepared submission waits for a human approval.

The loop, kept honest

Prepared by the platform. Decided by your people.

The loop is built so your team approves the work without carrying every moving piece by hand.

Action status

Sample data

ProposedPrepared by the platform
ApprovedYour coordinator signs off
ExecutingSubmission in flight
ExecutedOutcome posts to the ledger

Nothing executes before the approval step. That line never moves.

Approve

Bind the reviewed payload and destination before execution.

Reconcile

Keep the attempt open until external evidence resolves it.

Plain answers about the loop.

What is the prior authorization case workbench?: It is one place for the available requirement source, evidence findings, proposed action, transport posture, execution attempts, and confirmed disposition. Unknown remains a first-class state when policy or external status is unavailable.
Does Upstream file prior authorizations with payers automatically?: Not universally. A person approves every payer-facing action. A tenant can use a recently verified FHIR PAS rail where one is configured, or an assigned human-service path that requires structured submission and reconciliation evidence.
Does Upstream predict which cases will be denied?: Upstream can return a truth-labeled risk response and evidence findings. The current denial-risk service reports whether it used a promoted model or the conservative heuristic; we do not publish an accuracy claim without production evidence.
How is patient data protected in this loop?: PHI-bearing workflows use tenant-scoped access, encryption, BAA gates, and approval records. Third-party transmission remains disabled until the relevant contractual and capability checks pass.

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.

Start with Assist See a sample PA case