Healthcare Context Brain™

Prior Authorization Intelligence
Grounded in Certified Evidence

The first PA simulation engine that predicts approvals in under 5 minutes — zero hallucination, fully grounded in authoritative clinical evidence and payer-specific coverage logic.

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<5 min PA simulation, point of prescribing
>90% First-pass approval rate target
$42.5B Top 15 Medicare drugs — PA friction market
Zero PHI exposure — enforced by architecture
Our Mission
Help humans age with grace — one right medication, at the right time, without the fight.
The average US physician completes more than 45 prior authorization requests every week. Across tens of millions of requests annually — Medicare Advantage alone logged 53 million in 2024 — patients with diabetes, cancer, autoimmune disease, and cardiovascular conditions wait days, or give up entirely.

OPEX AI Consulting exists to eliminate that friction. Not by replacing clinical judgment — but by grounding every PA decision in the same FDA-approved truth the drug label has always contained. The rules were always there. We make them computable.
Who We Serve

Three Buyers. One Engine.

The Healthcare Context Brain™ delivers different value to each stakeholder — powered by the same knowledge graph.

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Health Plans & Payers

Pain: CMS-0057-F Deadline

PA processing costs $11–$40 per claim. CMS-0057-F now mandates 72-hour turnaround for urgent requests and 7 days for standard — manual review at scale is no longer viable.

→ Automate PA logic. Reduce admin cost. Stay compliant.
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Pharmaceutical Companies

Pain: 30% Rx Abandonment

One in three patients abandons a prescription after a PA denial. Your drug gets approved by FDA — then blocked by payer paperwork.

→ Predict denials before they happen. Protect your formulary position.
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Health Systems & Providers

Pain: Physician Burnout

Physicians spend 14+ hours per week on administrative tasks. PA is the single largest driver. It pulls time from patients.

→ Know before you prescribe. First-pass approval, every time criteria are met.
The Architecture

How It Works

A federated two-layer system. Proprietary clinical intelligence lives in the cloud. Patient data never leaves the EHR.

Step 01

EHR Query

Patient data — diagnosis, medications, labs, payer — stays on-prem inside the EHR. No PHI ever leaves the firewall.

Step 02

Proprietary Intelligence Layer

Anonymous clinical parameters are matched against our proprietary evidence engine — authoritative clinical guidelines, regulatory standards, and payer-specific PA criteria.

Step 03

Evidence-Grounded Match

Every recommendation is grounded in certified clinical evidence — indication, contraindication, step therapy, dosing. Zero hallucination by design.

Step 04

PA Recommendation

Result delivered in under 5 minutes with full audit trail: clinical evidence citation, payer rule citation, approval likelihood score.

Why OPEX AI

What Makes This Different

Most PA tools use general-purpose AI that hallucinates outdated drug data. We don't.

Authoritative Clinical Evidence as Ground Truth

Every drug decision in our proprietary engine is sourced from certified, continuously updated regulatory and clinical data — indications, contraindications, black box warnings, interactions. Updated same day as label changes.

Deterministic, Not Probabilistic

The same clinical query returns the same answer every time. No variance. No hallucinated payer rules. Our proprietary reasoning engine is auditable, deterministic, and defensible in a regulatory context.

Zero PHI Exposure by Architecture

Patient data stays inside the EHR on-prem. The system never sees real patient records. HIPAA compliance is not a policy — it is enforced by the architecture itself.

Customer Data Never Trains Our Model

Your payer rules, your patient populations, your formulary decisions — none of it is used to train or fine-tune anything. Ever. Your proprietary data stays yours.

Mohan Nadarajah
Founder & CEO, OPEX AI Consulting Services LLC

Mohan brings 30 years of frontline healthcare commercial experience — from pharmaceutical sales and market access strategy to payer operations and CMS regulatory compliance. He has worked across every layer of the US healthcare system: at Merck, Amgen, Mayo Clinic, IQVIA, and Cytokinetics, in therapeutic areas spanning oncology, immunology, cardiovascular, respiratory, and diabetes.

The Healthcare Context Brain™ is not a technology looking for a problem. It is 30 years of operational pattern recognition — why physicians prescribe what they prescribe, how payers construct PA criteria, what makes a drug succeed or fail at the formulary level — encoded as a proprietary, computable intelligence system.

Merck 1993–2009 Mayo Clinic IQVIA Amgen 2013–2021 Cytokinetics Opex.ai LLC 2022–present
  • Prior authorization workflows and payer operations — commercial, Medicare, Medicaid
  • Pharmaceutical market access — formulary strategy, step therapy, exception protocols
  • CMS regulatory compliance — CMS-0057-F, Part D, TEFCA, HIPAA
  • Specialty pharmacy operations — oncology, immunology, rare disease
  • Multi-stakeholder decision logic — provider, payer, patient, pharma, regulator
  • Hidden incentive architectures — why payers deny, why physicians abandon
  • Patient journey mapping — birth to end of life, disease progression, treatment selection
  • Therapeutic expertise — oncology, autoimmune, cardiovascular, diabetes, respiratory, osteoporosis

Ready to See It?

We are currently in strategic partnership conversations with health plans, pharmaceutical manufacturers, and health systems. Briefings are by invitation.

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mohann@fjfrontier.com  ·  Austin, TX  ·  OPEX AI Consulting Services LLC