Key points
- UK insurers paid a record £4 billion in private medical insurance claims in 2024, for 1.8 million claimants.1
- US practices complete 39 prior authorization requests per physician each week, taking physicians and staff 13 hours, in an AMA survey of 1,000 physicians.2
- From 2026, payers covered by the CMS prior authorization rule must decide standard requests within seven calendar days and give a specific reason for any denial.3
- AI assembles the eligibility query, the claim and the authorisation request from the clinic's own records, and a person at the clinic confirms each one before it is submitted.6
Summary
AI prepares most of the insurance work, from collecting policy details and drafting the eligibility check to building the claim from the signed note and drafting a prior authorisation request. A person at the clinic confirms the codes, the cover and the final submission, because the clinic and the clinician are accountable for every claim.
Insured patients arrive with cover confirmed and leave with the claim already built. AI assembles each check and claim from the clinic's own records, and a person at the clinic confirms every one before it reaches the insurer.
See it in your clinicThirty minutes on your own patients and doctors.
Request a demoSee an insured booking arrive with the policy details gathered and the eligibility check drafted, ready for your team to confirm.
| Task | AI prepares | A person checks |
|---|---|---|
| Policy details at booking | Requests insurer, policy and authorisation numbers in the booking conversation | Details match the patient's record and documents |
| Eligibility and cover | Drafts the eligibility query and a summary of what the policy covers | Cover applies to this treatment and this clinician |
| Patient explanation | Drafts a message on cover, excess and any likely shortfall | Front desk approves before it sends |
| Prior authorisation | Drafts the request from the signed note and attaches records | Clinician confirms the clinical justification |
| Codes | Suggests codes from the signed note | Clinician confirms every code |
| Claim | Builds the claim and invoice from the confirmed record | Admin team reviews and submits |
| Rejection or shortfall | Reads the reason and drafts the correction and the patient message | Admin owner approves the resubmission and the message |
Insured patients are a growing share of the diary
The ABI reports that UK insurers paid a record £4 billion in individual and workplace private medical insurance claims in 2024, up 13% from £3.57 billion in 2023. People covered rose 4% to 6.5 million, and 1.8 million made a claim, up 10%.1 Each claim starts with a policy number at a clinic's front desk.
Eligibility first, claim second
A patient who arrives with cover confirmed and any excess explained has a better visit, and the claim afterwards has little left to go wrong.
In the US, the eligibility check is a HIPAA standard transaction. Under 45 CFR 162.1201 it is a provider's inquiry to a health plan about a person's eligibility, coverage and benefits, and the plan's response.4 Elsewhere the format varies by insurer, and the check confirms the treatment and clinician are covered and what the patient will pay.
AI collects the policy details at booking, drafts the eligibility query in the insurer's format, and drafts a short note to the patient on what the policy covers. A person checks it and sends it.
Prior authorisation with a clear deadline
In an AMA survey of 1,000 US physicians in late 2024, practices completed an average of 39 prior authorization requests per physician each week, physicians and staff spent 13 hours on them, and 40% of physicians had staff working on prior authorization alone.2 These are self-reported US figures.
Under the CMS Interoperability and Prior Authorization final rule, Medicare Advantage organisations, state Medicaid and CHIP programmes and their managed care plans must decide urgent requests within 72 hours and standard ones within seven calendar days, and from 2026 must give a specific reason for any denial.3 The rule covers those payers only, and excludes drugs.3
AI drafts the request from the signed note, attaches the supporting records and tracks the deadline. The clinician owns the clinical justification and confirms it before submission. More in prior authorization automation.
What AI prepares and what people check
The table below draws the line. A named person at the clinic checks everything before it reaches an insurer.
Insurance eligibility and claims are part of wai Admin, priced per location on the pricing page.5 wai extracts codes from consult notes and prepares claims for insurers, and a person approves before anything sends.6 The codes come from the clinician-signed note, as set out in the billing and coding workflow.
Rejections worked as a daily queue
A rejection arrives as a task with the reason, the claim and the record attached, assigned to one person, and is worked within days so there is time to resubmit before the insurer's deadline.
AI reads the rejection and drafts the correction, plus a message to the patient if a shortfall falls to them. The team approves each one. For UK insured billing, Healthcode billing for private clinics covers the submission chain.
Where to start
List last month's insured visits. For each, note whether cover was confirmed before the visit, how many days passed before the claim went out, and whether it was paid in full first time.
Fix the earliest gap first. Collect policy details at booking, confirm cover before the day, build the claim from the signed note on the day, and give rejections one owner. Track the same numbers monthly until every insured patient arrives covered and every claim leaves on the day.
Bring a month of insured visits. We show you the checks and claims drafted from your own records, with your team approving each one.
Frequently asked questions
Can AI submit insurance claims on its own?
AI prepares the claim from the signed record, and a person at the clinic reviews and submits it. With wai, a person approves before anything sends.6
Who is responsible for the codes on a claim?
The clinician confirms the codes and the clinical justification, and the clinic is accountable for the claim. Software suggests codes for them to confirm.
How fast must US payers decide prior authorizations now?
Under the CMS rule, covered payers such as Medicare Advantage and Medicaid plans must decide urgent requests within 72 hours and standard requests within seven calendar days, and give a specific denial reason from 2026. Drugs are excluded.3
What is an eligibility check in the US?
A HIPAA standard transaction in which a provider asks a health plan about a person's eligibility, coverage and benefits, and the plan responds.4
Is insurance work worth automating for a small UK clinic?
It depends on the insured share of the diary. UK insurers paid £4 billion in claims for 1.8 million claimants in 2024, a material share of revenue for many private clinics.1
Sources
- 1Association of British Insurers, 2026Insurers process record £4bn across individual and workplace health schemes (archived copy read 14 Oct 2026)Read 14 October 2026Read source
- 2American Medical Association, 2025Fixing prior auth, Nearly 40 prior authorizations a week is way too manyRead 14 October 2026Read source
- 3Centers for Medicare and Medicaid Services, 2024CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheetRead 14 October 2026Read source
- 4Electronic Code of Federal Regulations, US Government, 202645 CFR 162.1201, Eligibility for a health plan transactionRead 14 October 2026Read source
- 5wai, 2026wai pricingRead 14 October 2026Read source
- 6wai, 2026wai Admin, the front desk and back officeRead 14 October 2026Read source
Cover confirmed before the visit, and every claim out the same day.
Fifteen minutes on your own insured visits, with every check and claim prepared for your team to approve. We reply within one working day.
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