Reimbursement & Prior Auth Vendors
Reimbursement support, electronic prior authorization, benefit verification and coverage-determination services.
32 vendors profiled
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Parsippany, NJ
Agadia's PAHub is a HITRUST-certified utilization management platform used by health plans, PBMs, and TPAs to automate end-to-end electronic prior authorization for both pharmacy and medical benefits, with auto-decisioning rules, NLP, and FHIR-based interoperability for CMS-0057-F compliance.
- PAHub electronic prior authorization
- medical and pharmacy UM automation
- auto-decisioning rules engine
- CMS-0057-F compliance tooling
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New York, NY
Anterior builds clinician-led AI (its agent 'Florence') that automates clinical review for health plans, starting with prior authorization and extending to care management and payment integrity, reporting 99%+ clinical accuracy and ~75% faster review cycles.
- AI clinical review for prior authorization
- medical record preparation
- utilization management co-pilot
- payment integrity
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Jacksonville, FL
Availity runs a national payer-provider network and EDI clearinghouse whose Essentials portal lets providers check authorization requirements, submit prior authorizations with clinical attachments, and track status across multiple health plans in one place. It supports FHIR-based prior authorization APIs for CMS-0057-F compliance.
- multi-payer provider portal
- EDI clearinghouse
- prior authorization submission and status
- eligibility and benefits
- FHIR interoperability for CMS-0057-F
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Washington, DC
Banjo Health provides AI-driven prior authorization decisioning software for health plans and PBMs, automating clinical criteria into decision trees and streamlining PA, appeals, and grievances workflows.
- BanjoPA prior authorization automation
- clinical criteria digitization
- appeals and grievances management
- integration with ePA vendors and claims systems
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Nashville, TN
Change Healthcare is the largest US healthcare clearinghouse, processing over 15 billion transactions annually (roughly 40% of all US medical claims) across eligibility, claims, remittance, and prior authorization. It has operated as part of Optum (UnitedHealth Group) since 2022.
- EDI clearinghouse
- claims and remittance management
- prior authorization transactions
- eligibility APIs
- payment accuracy
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Claimable is a patient-facing AI appeals platform that generates and submits customized appeals for denied health insurance claims, backed by clinical evidence and policy analysis, covering 85+ medications and dozens of conditions for a flat per-case fee.
- AI-generated insurance appeals
- denial analysis
- appeal submission and delivery
- manufacturer/partner-funded patient appeals
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Boston, MA
Cohere Health provides clinical-grade AI intelligent prior authorization for health plans, automating clinical data extraction and real-time decisioning; it works with nearly 600,000 providers and processes over 12 million PA requests annually, auto-approving up to 90%.
- intelligent prior authorization platform
- AI clinical decisioning
- payment integrity
- provider collaboration tools
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CompleteBI is an early-stage healthcare data-infrastructure company whose BenLinQ product is an API gateway for real-time completed benefits investigation, giving manufacturers, patient support programs, PBMs, and technology vendors structured access to eligibility, coverage, formulary, and prior authorization data.
- real-time benefits investigation API
- eligibility and coverage data
- formulary and PA requirement data
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Columbus, OH
CoverMyMeds automates electronic prior authorization and medication access workflows connecting providers, pharmacies, payers, and pharma manufacturers. Founded in 2008 and acquired by McKesson for $1.1B in 2017, it is one of the largest ePA networks in the US.
- electronic prior authorization
- real-time benefit check
- specialty patient support technology
- affordability solutions
- e-enrollment
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San Francisco, CA
Develop Health is a GenAI-native platform that automates pharmacy-benefit verification and the full prior authorization cycle (submission, follow-up, denials, appeals) inside EHR and virtual care workflows. It raised $14.3M in August 2025 and supports hundreds of thousands of patients monthly.
- AI benefit verification
- automated prior authorization and appeals
- real-time coverage and out-of-pocket estimates
- EHR integrations (athenahealth)
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Louisville, KY
eBlu Solutions provides a single-portal platform for real-time benefit investigation, electronic prior authorization, and manufacturer savings program enrollment for infusion and injection specialty therapies, supporting 1,200+ payers. Founded in 2012 in Louisville, KY; acquired in 2025 and rebranded as CareTria Provider Connect in April 2026.
- real-time benefit investigation
- electronic prior authorization
- medical and pharmacy benefit support
- manufacturer savings program connectivity
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Bluffton, SC
EviCore by Evernorth is the largest delegated utilization management and medical benefit management company in the US, making evidence-based prior authorization determinations for health plans in areas like imaging, cardiology, oncology, and specialty care; its intelliPath ePA tool integrates PA into provider EHR workflows.
- delegated prior authorization and UM
- evidence-based medical policy
- intelliPath electronic prior authorization
- site-of-care management
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Forus (formerly Tandem) is an AI-powered medication access network embedded in physician workflows that automates benefits verification, prior authorization, appeals, financial assistance enrollment, and pharmacy routing across drugs, payers, and pharmacies, free to providers and patients.
- prior authorization automation
- real-time benefits verification
- appeals automation
- financial assistance identification
- pharmacy fulfillment routing
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Orlando, FL
Humata Health, founded by former Verata Health founder Jeremy Friese, MD, provides AI-driven touchless prior authorization technology for providers and payers, using machine learning to assemble required clinical documentation and flag likely denial reasons before submission.
- AI prior authorization automation
- clinical documentation recommendations
- denial risk flagging
- touchless PA approvals
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San Francisco, CA
Infinitus builds voice AI agents that automate payer phone calls for benefit verification, prior authorization follow-up, and claims workflows on behalf of pharma patient support programs, specialty pharmacies, and providers. Its AI agents have powered 100M+ minutes of healthcare conversations.
- AI-automated benefit verification calls
- prior authorization follow-up automation
- PBM discovery
- structured payer data output for hub workflows
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Spring, TX
Infinx combines AI-driven software and global specialist teams to deliver patient access and revenue cycle services for providers, including eligibility verification, benefits checks, prior authorization automation, claims submission, and denials management.
- prior authorization automation
- eligibility and benefit verification
- claims and A/R management
- denials management
- RCM outsourcing
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Bowie, MD
Healthcare data and cloud analytics company whose MORE2 Registry is one of the largest US primary-source claims datasets, spanning over 400 million unique lives and 90+ billion medical events. Its life sciences business supports commercial analytics, payer quality insights, and RWE on the Inovalon ONE Platform.
- MORE2 Registry claims dataset
- payer and Medicare Advantage analytics
- data linking for commercial and RWE use
- commercial analytics on the Inovalon ONE Platform
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Interra Health was formed in March 2026 through the merger of DoseSpot (ePrescribing) and Arrive Health (real-time prescription benefit and price transparency), with Bain Capital Tech Opportunities as majority owner. The combined profitable company serves roughly 800,000 prescribers and is projected to exceed $100M revenue in 2026.
- ePrescribing infrastructure (DoseSpot)
- real-time prescription benefit and price transparency (Arrive Health)
- eligibility and medical benefit verification (pVerify)
- prescriber and patient engagement
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Itiliti Health provides FHIR-native electronic prior authorization infrastructure for health plans, implementing the CMS-0057-F required CRD, DTR, and PAS transactions along with PA requirement lookup and automation tools that reduce administrative burden.
- FHIR CRD/DTR/PAS implementation
- CMS-0057-F compliance
- PA requirement transparency
- payer PA workflow automation
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Mandolin provides an AI-agent platform that automates the referral-to-reimbursement path for specialty drugs — intake, benefits verification, prior authorization, payer follow-up, billing, and appeals — for infusion centers, specialty pharmacies, and health-system specialty programs.
- AI prior authorization automation
- benefits verification
- billing and payer follow-up
- appeals support
- EHR and manufacturer-hub coordination
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Tampa, FL
MHK (formerly MedHOK), part of the Hearst Health network, provides the CareProminence SaaS platform unifying medical utilization management, pharmacy prior authorization, care management, and complaints/appeals/grievances for health plans and PBMs across Medicare, Medicaid, and commercial lines.
- medical UM and pharmacy PA software
- complaints, appeals and grievances
- medication therapy management
- compliance workflows
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Mesa, AZ
Myndshft provides real-time medical and pharmacy benefit verification and automated prior authorization SaaS covering 95% of insured US patients and 600+ payers. Founded in 2018, its assets were acquired by DrFirst in April 2024.
- real-time medical benefit checks
- automated prior authorization
- eligibility verification
- payer rules engine
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PrescriberPoint is a free, HIPAA-compliant, AI-powered prior authorization workflow platform for prescribers that automates the full PA lifecycle — from script capture in the EMR through payer questions, approval, appeals, and pharmacy routing — alongside drug coverage and affordability information.
- AI-assisted prior authorization drafting
- PA triage before pharmacy submission
- appeals workflow
- coverage and out-of-pocket insights
- savings program enrollment
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Prosper AI builds healthcare voice AI agents that call payers and patients to verify benefits and eligibility, check and initiate prior authorizations, track claims status, and handle scheduling and intake, writing results back into the EHR or system of record.
- AI payer phone calls
- benefit and eligibility verification
- prior authorization initiation and status
- claims status
- patient intake and scheduling
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New Albany, OH
Rhyme (formerly PriorAuthNow) operates an EHR-integrated prior authorization network that unites payers and providers for touchless, real-time PA decisions, processing over 4 million prior authorizations annually for large health systems.
- EHR-integrated PA submission
- LiveAuth touchless authorization network
- payer-provider shared PA visibility
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San Francisco, CA
Medical-benefit prior authorization platform used by physician practices to submit, track, and manage prior authorizations for buy-and-bill specialty drugs; pharma manufacturers sponsor the platform to reduce access friction for their brands.
- medical benefit prior authorization workflow
- benefit verification
- enrollment support
- brand-sponsored access programs
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New York, NY
Silna Health uses AI to handle prior authorizations, specialty-specific benefit checks, and ongoing insurance eligibility monitoring for outpatient and therapy providers, clearing patients for care before visits.
- AI prior authorization management
- benefit checks
- insurance eligibility monitoring
- coverage change detection
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Arlington, VA
Surescripts operates the largest US e-prescribing network and provides electronic prior authorization (including Touchless PA) and Real-Time Prescription Benefit price transparency used across prescriber, pharmacy, and PBM workflows. Its network reaches hundreds of thousands of prescribers nationwide.
- e-prescribing network
- electronic prior authorization
- Real-Time Prescription Benefit
- medication history
- specialty patient enrollment
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New York, NY
Tennr builds healthcare-specific vision-language models (RaeLM) that read faxed referrals and clinical documents, extract structured data, evaluate them against payer criteria to prevent denials, and automate downstream benefit and authorization workflows. It processes about 10 million documents per month.
- AI referral and document intake
- payer criteria checks to flag denial risk
- benefits and eligibility workflows
- referral status visibility (Tennr Network)
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San Francisco, CA
Trellis AI is a Stanford AI Lab spinout whose AI agents automate pre-service operations — document intake, prior authorizations, appeals, benefits investigation, and eligibility checks — for specialty providers, specialty pharmacies, infusion centers, diagnostic labs, and health systems.
- AI prior authorization submission
- automated appeals
- benefits investigation
- eligibility checks
- EHR-integrated intake
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Huntington Beach, CA
Valer (formerly Voluware) provides a cloud platform that automates submission, verification, and management of prior authorizations and referrals across all payers and service types for hospitals, health systems, and physician practices, with EHR integrations including Epic.
- prior authorization submission automation
- referral management
- payer portal aggregation
- authorization status verification
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zPaper is a Salesforce-native document exchange and data-capture platform that centralizes fax, email, portal, and digital document workflows for pharma hub services, patient access, and provider communications, supporting 75+ drug brands. Its dataDocuments product replaces static PDFs with structured, FHIR-enabled containers.
- Salesforce-native fax and document workflow
- enrollment form digitization and data capture
- FHIR-enabled structured documents (dataDocuments)
- document generation and audit tracking
