MAIC | Prior Authorization Generator

Input Mode

Patient Name

DOB

Claim / Case #

Date of Injury

Insurer / Carrier

Adjuster

Diagnosis (ICD-10)

Requested Service / Procedure

CPT Code(s)

Treating Provider

Mechanism of Injury

Current Symptoms & Functional Limitations

Prior Treatment / Response

MMI Status

Work Status

Additional Clinical Notes

Signature Block

Signing Physician

Credentials

Title / Specialty

NPI

Phone

Fax

Upload clinical notes, face sheets, IME reports, or prior correspondence. The AI will extract relevant data and generate PA documents.

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Drag & drop files or click to browse

PDF, DOCX, TXT, images supported

Additional Instructions

eCW via Keragon API
Paste the patient data payload returned from your Keragon webhook trigger. The tool will parse all structured fields automatically.

Keragon / eCW JSON Payload

Requested Service

Additional Clinical Context

Clinical Guidelines

✓

NY WC MTG
NYSWCB

✓

AMA Guides
MMI / Disability

ODG
Work Loss

MCG / Milliman
Utilization

Generate Outputs

✓

Full PAR Letter Narrative

✓

Supporting Doc Checklist Structured

Appeal Letter Template On Denial

MAIC · Medalliance Medical Health Group · Bronx NY

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PA Cover Sheet will appear here

Complete the form on the left and click Generate

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PAR Letter will appear here

Complete the form on the left and click Generate

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Supporting Document Checklist will appear here

Complete the form on the left and click Generate

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Appeal Letter will appear here

Select "Appeal Letter Template" and click Generate