Prior authorization reviewer
A kolm template that reads clinical notes and CPT codes, maps them against medical-necessity criteria, and outputs a structured prior-auth recommendation. PHI is redacted before any inference. The criteria-mapping is auditable, the K-score gate is locked at 0.95, and every call ships a 4-ring HMAC receipt your medical director can re-verify offline.
Input & output spec
One request per authorization. The reviewer reasons over clinical notes against your plan-specific medical-necessity criteria and returns a recommendation with the matched criteria list.
input
{
"auth_request_id": "PA_2026_009823",
"member_id": "<redacted>",
"requesting_provider": "1234567893",
"requested_cpt": ["70553"], // MRI brain w/ contrast
"diagnosis_icd10": ["G43.909", "R51"],
"clinical_notes": "<PHI-bearing clinical summary>",
"prior_treatments": ["trial_NSAID", "trial_triptan"],
"urgency": "routine",
"plan": "PPO-Gold-2026"
}
output
{
"recommendation": "Approve", // or "Deny" / "Request more info"
"criteria_met": ["PA-MRI-BRAIN-3.1", "PA-MRI-BRAIN-3.4"],
"criteria_unmet": [],
"redacted_summary": "60d migraine refractory to NSAID + triptan trial; rule-out indication met.",
"confidence": 0.92,
"requires_md_review": false,
"appeal_letter_url": null
}
4-ring receipt schema
Every prior-auth decision ships a receipt your medical director and external auditors can re-verify offline. The chain proves the input clinical context, the criteria mapping, the recommendation, and the seal.
Verify command: kolm verify --hash <receipt_hash>. Runs locally against the seal, no network required.
BAA fast-track
Health plans on a BAA see kolm production-ready in two business days. The customer-hosted bridge runs in the tenant network boundary; PHI is processed there and never crosses our infrastructure; the audit log is yours to keep.
how it works
# 1. Sign the BAA (legal-team turnaround) [ DocuSign · 48 hours typical · mutual NDA in same envelope ] # 2. Provision the bridge in your VPC $ kolm bridge install \ --provider aws \ --region us-east-1 \ --baa <baa-id> # 3. Compile this template against your seed examples $ kolm compile --spec prior-auth-review.spec.json \ --examples ./your-anonymized-auths.jsonl \ --gate 0.95 \ --out prior-auth.kolm
what we sign
- HIPAA Business Associate Agreement - HIPAA Security Rule §164.308 (admin safeguards) - HIPAA Security Rule §164.310 (physical safeguards) - HIPAA Security Rule §164.312 (technical safeguards) - Breach Notification §164.404 - Subcontractor flow-down (none — kolm holds no PHI) - Audit-log retention (6 years, your S3 bucket)
Get the template
Two ways to take this live. Self-serve with the sample artifact, or kick off a BAA conversation if you need PHI day one.
The spec is a portable JSON file. Drop it into kolm compile --spec with your anonymized seed examples to build a private .kolm tagged LicenseRef-kolm-default-1.0 by default; pass --license to tag it differently.