Generative AI Powered Prior Authorization Decision Framework

A method comprising:

• accessing a plurality of clinical guideline vector embeddings associated with a plurality of clinical guidelines;
• creating a request query for a medical procedure for a patient;
• generating a query vector embedding for the request query by applying a vector embedding function to the request query;
• calculating similarity scores between the query vector embedding and the each of the plurality of clinical guideline vector embeddings;
• identifying a subset of clinical guideline vector embeddings having a similarity score with the query vector embedding above a threshold value, wherein the subset of clinical guideline vector embeddings correspond to a subset of clinical guidelines;
• and
• generating a prompt for providing to a generative AI model for generating a prior authorization report;
• providing the prompt to the generative AI model;
• applying the generative AI model to the subset of clinical guidelines and patient data to determine a target clinical guideline and generate a prior authorization report responsive to the prompt, wherein the patient data comprises the request query, health plan details, and patient details;
• and
• based on the target clinical guideline and the patient data, generating, by the generative AI model, a prior authorization report responsive to the prompt;
• wherein the patient is treated based on an approval of the medical procedure in the prior authorization report,
• wherein the method is performed by at least one device including a hardware processor.

A system comprising:

• at least one device including a hardware processor;
• the system being configured to perform operations comprising:
• accessing a plurality of clinical guideline vector embeddings associated with a plurality of clinical guidelines;
• creating a request query for a medical procedure for a patient;
• generating a query vector embedding for the request query by applying a vector embedding function to the request query;
• calculating similarity scores between the query vector embedding and the each of the plurality of clinical guideline vector embeddings;
• identifying a subset of clinical guideline vector embeddings having a similarity score with the query vector embedding above a threshold value, wherein the subset of clinical guideline vector embeddings correspond to a subset of clinical guidelines;
• and
• generating a prompt for providing to a generative AI model for generating a prior authorization report;
• providing the prompt to the generative AI model;
• applying the generative AI model to the subset of clinical guidelines and patient data to determine a target clinical guideline and generate a prior authorization report responsive to the prompt, wherein the patient data comprises the request query, health plan details, and patient details;
• based on the target clinical guideline and the patient data, generating, by the generative AI model, a prior authorization report responsive to the prompt;
• wherein the patient is treated based on an approval of the medical procedure in the prior authorization report.