44% faster appeals turnaround at a regional payer — GenAI evidence triage
Member and provider appeals were a paperwork mountain that missed regulatory turnaround windows. pronix.ai built a GenAI evidence-triage workflow with reviewer-in-the-loop — 44% faster turnaround, cleaner first-pass overturn decisions and NCQA-audit-ready evidence trails.
Regional health payer, 3.4M members · Salesforce Health Cloud · Azure OpenAI · document AI
- Client
- Regional health payer, 3.4M members
- Industry
- Health Payers
- Platform
- Salesforce Health Cloud · Azure OpenAI · document AI
*Representative outcome; results vary by client, scope and platform configuration.
The challenge
Appeals reviewers spent the majority of the case on evidence assembly, not clinical judgment. Missed CMS turnaround windows drew corrective-action plans, and evidence artifacts sat across four repositories.
Our approach
Evidence assembly agent
Pulled every relevant clinical, policy and prior-decision artifact into a single reviewer packet — with citations.
Overturn-likelihood surfacing
Model surfaced a probability of overturn and the evidence that drove it — reviewer decided, not the model.
Reviewer workbench
Physician and nurse reviewers annotated the packet in place; annotations became the audit trail.
NCQA-formatted audit export
One-click export of the appeal file in NCQA-audit-ready format.
CMS turnaround guardrails
Live SLA countdown per case with escalation triggers — missed turnarounds became a preventable exception, not a monthly discovery.
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Read →Illustrative case study. Scenarios, metrics, quotes and client details are representative composites based on Pronix engagements and industry benchmarks unless a named client is shown with written consent. Outcomes vary by client, scope, data quality and platform configuration. Nothing on this page is a guarantee, warranty or professional advice. See our Terms of Use for the full disclaimer.
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