Case Health AI
Case Health AI builds proprietary AI agents (CALLM and EVALLM) that automate prior authorization intake, evaluation, and approval or denial decisions for U.S. health plans, integrating with existing Utilization Management software such as HealthEdge GuidingCare.
- Company typePrivate
- Founded2025
- HeadquartersSan Francisco, United States
- Headcount1–10
- GTM typeB2B
- OfferingSoftware
What Case Health AI does
Case Health AI builds AI agents that automate prior authorizations for U.S. health plans and managed care organizations. The platform consists of two proprietary large language models—CALLM™ (Clinical Abstraction LLM) for intake and EVALLM™ (Evaluation LLM) for criteria verification—plus a policy-to-decision-tree converter that translates payer authorization policies (PDF or text) into editable logic blocks for clinical automation. The product processes structured data, free text, and images (including handwriting) on prior authorization documents, evaluates cases against health plan criteria, claims history, and compendiums, and routes approvals, denials, or outreach back into the customer's existing utilization management (UM) software via HealthEdge GuidingCare integration.
The company sells as a B2B SaaS subscription with usage-based components to enterprise health plans, using an enterprise field-sales motion with Calendly-scheduled demos and a 'no rip-and-replace' positioning. Pricing is quote-based with annual billing and is not publicly disclosed. The customer segment is exclusively health plans/payers, and the go-to-market emphasizes integration with incumbent UM systems rather than displacement.
Founded in 2025 and headquartered in San Francisco, the company is led by Co-Founder & CEO Dr. Mas Hossain (Y Combinator alumnus) and Co-Founder & COO Dr. Fadi Shamma (formerly of Wellcare), with Dr. Julie Shamma as Chief Medical Officer (formerly of Centene) and Dr. Sam Toney as a board advisor. The team is described as a mix of AI engineers, doctors, and clinical pharmacists with alumni ties to Stanford, Centene, Wellcare, Blue Cross Blue Shield, and Y Combinator. The company is venture-backed (a16z Scout Fund, Pioneer Fund, Theory Forge Ventures), HIPAA-aligned with SOC 2 Type 2 certification, and has HITRUST CSF certification in progress. Operating scale is 1-10 employees with operations confined to the United States.
Case Health AI firmographics
Firmographics- Name
- Case Health AI
- Legal name
- Case Health AI, Inc.
- Website
- https://casehealth.ai
- Company type
- Private
- Founded year
- 2025
- Operating status
- Operating
- Headcount range
- 1–10 employees
- Short description
- Case Health AI builds proprietary AI agents (CALLM and EVALLM) that automate prior authorization intake, evaluation, and approval or denial decisions for U.S. health plans, integrating with existing Utilization Management software such as HealthEdge GuidingCare.
- Ownership category
- akta.pro rank
Case Health AI industry classification
Industry- Product category
- Healthcare Prior Authorization Automation
- NAICS
- Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds (524292), Claims Adjusting (524291)
- SIC
- Services-Prepackaged Software (7372), Services-Computer Programming, Data Processing, Etc. (7370)
- akta.pro primary industry
- Medical Billing & Coding Automation (HLACACAA)
- akta.pro secondary industry
- EHR Extensions, APIs, App Marketplaces & SMART-on-FHIR Apps (HLACAAAN)
Keywords
Where Case Health AI is headquartered
LocationHeadquarters
- HQ city
- San Francisco
- HQ country
- United States
- HQ region
- North America
Offices1 record
Markets served
Case Health AI business model
Business model- GTM type
- B2B
- Offering type
- Software
- Cost components
- Personnel, Technology or R&D, Marketing or Sales, Operations, Infrastructure
Revenue model
- SaaS Platform Subscription: Case Health AI operates as a B2B SaaS company providing AI agents that automate prior authorization for health plans. The platform is subscription-based with usage components, as evidenced by the terms of service mentioning 'subscription or usage-based fees.' Health plans pay to integrate and use the AI automation platform.
Pricing tiers
| Model | Billing | Price |
|---|---|---|
| Subscription | Annual | Enterprise tier - health plan focused |
Go-to-market motion1 record
Distribution channels1 record
Marketing channels3 records
Case Health AI product offering
Product offeringCore offering
Case Health AI provides a B2B SaaS platform of integrated AI agents that automate prior authorizations for health plans. The platform's proprietary CALLM and EVALLM models handle end-to-end intake, criteria verification, and approval/denial determination, integrating with existing Utilization Management software (e.g., HealthEdge GuidingCare) without replacing it. It is sold to health plan operations teams via enterprise subscriptions.
Product overview
Case Health AI is a unified AI platform for automating prior authorizations in health plans. The core offering consists of proprietary AI agents (CALLM for intake abstraction and EVALLM for case evaluation) that integrate with Utilization Management software like HealthEdge GuidingCare. The platform also includes a policy-to-decision-tree converter that transforms messy policy documents into structured, AI-ready logic blocks. Together, these components enable end-to-end automation of prior auth processing—from intake to determination—while maintaining a complete audit trail and clinical accuracy.
Differentiator
Problem solved
Functional benefit
Products and services
- AI Prior Authorization Agents Platform End-to-end AI-driven prior authorization automation for US health plans, autonomously handling intake, criteria verification, and approval/denial determination. Integrates with existing Utilization Management software such as HealthEdge GuidingCare without rip-and-replace. Built for enterprise health plan operations teams managing high prior auth case volumes.
Quantifiable outcome
- 99.69% accuracy in decision making
- +2 more outcomes
Companies that use Case Health AI
Customer profileSegments1 record
Ideal customer profiles1 record
Case Health AI technology and API
TechnologyTechnology focussed Yes
API detail
- Has API
- Yes
- API docs
- API detail
Core technology
AI maturity
App detail
Integration1 record
AI capability7 records
Feature4 records
Case Health AI partnerships and signals
Strategic signalPartnerships
One partnership is on record.
- HealthEdge GuidingCarecoreCase Health AI is an official integration partner with HealthEdge GuidingCare Decision Intelligence Ecosystem. The partnership integrates clinical AI solutions to enhance utilization management (UM), streamline prior authorizations, and reduce delays and administrative costs for health plans.
Scale indicators3 records
Recent moves6 records
Expansion highlights5 records
Case Health AI competitors and assessment
Company assessmentBroad incumbents
- HealthEdge Software: Provider of GuidingCare and other payer technology platforms, and an active integration partner of Case Health AI. Functions as a channel partner and broader incumbent in the UM software stack, with potential to extend into prior-auth AI itself.
- R1 RCM: Large RCM and healthcare automation provider offering end-to-end patient access, prior auth, and claims workflows. Incumbent that could bundle prior-auth AI into existing payer/provider contracts, putting pressure on point solutions like Case Health AI.
- Olive AI: Healthcare AI automation platform serving hospitals, payers, and providers across revenue cycle and operational workflows including prior auth. Broader incumbent with a much larger installed base and capital pool, but with overlapping capabilities that compete for the same payer IT budget.
- Waystar: Public revenue cycle management software platform covering eligibility, prior authorization, claims management, and denials. Provides overlapping prior-auth capabilities to payer and provider customers as part of a broader RCM suite, representing both competitor and potential integration partner.
- Change Healthcare: Now part of Optum, Change Healthcare provides claims processing, prior auth, and revenue cycle solutions across the payer and provider ecosystem. Large incumbent whose scale, data assets, and integration footprint could overwhelm early-stage prior-auth AI startups.
Direct peers
- Cohere Health: AI-driven prior authorization and utilization management platform for health plans. Most direct competitor to Case Health AI, with similar buyer (payer medical directors), similar value proposition (clinical AI automating UM), and significantly more capital raised and larger payer footprint.
- Anterior: AI prior authorization platform serving health plans; named alongside Case Health AI in the HealthEdge GuidingCare Decision Intelligence Ecosystem announcement. Targets the same payer UM buyer with clinical-decision AI and is a direct head-to-head competitor in the same channel.
- Latitude Health: Healthcare AI company focused on prior authorization and clinical decision support for payers, also co-listed as a HealthEdge GuidingCare partner alongside Case Health AI. Closely comparable in product scope, buyer persona, and go-to-market approach.
- Infinx: Prior authorization and revenue cycle management automation vendor for providers and payers, with AI-driven workflows for eligibility, auth, and claims. Directly comparable technology stack and target buyer (payer UM teams) to Case Health AI.
Emerging players
- AKASA: AI-driven revenue cycle automation company applying generative and agentic AI to authorization, coding, and claims workflows. Comparable in stage-of-maturity and AI-first approach, with overlap on prior auth as part of a broader RCM platform.
Market position
Strengths5 records
Weaknesses5 records
Competitive moat4 records
Key risks6 records
Key highlights7 records
Customer concentration
Case Health AI social profiles
Digital presenceCase Health AI compliance and trust
Trust signalCompliance3 records
Case Health AI financial estimates
Financial estimateRevenue estimate
Valuation estimate
Case Health AI leadership team
Management profileNumber of profiles
Profiles4 records
Case Health AI funding detail
Funding detailFunding overview
Funding rounds2 records
Investors3 records
Funding detail is available on the Subscription and Enterprise plan.Contact sales →
Case Health AI M&A and investment
M&A and investmentM&A
Investments
M&A and investment is available on the Subscription and Enterprise plan.Contact sales →
Frequently asked questions about Case Health AI
What does Case Health AI do?
Case Health AI provides a B2B SaaS platform of integrated AI agents that automate prior authorizations for health plans. The platform's proprietary CALLM and EVALLM models handle end-to-end intake, criteria verification, and approval/denial determination, integrating with existing Utilization Management software (e.g., HealthEdge GuidingCare) without replacing it. It is sold to health plan operations teams via enterprise subscriptions.
Is Case Health AI a public or private company?
Case Health AI is a private company. It is classified as venture growth investor backed and is currently operating.
When was Case Health AI founded?
Case Health AI was founded in 2025. It employs 1 to 10 people.
Where is Case Health AI based?
Case Health AI is headquartered in San Francisco, United States, in the North America region.
How does Case Health AI make money?
One revenue line is on record: saaS Platform Subscription.
Who are Case Health AI's main competitors?
Broad incumbents on record are HealthEdge Software, R1 RCM, Olive AI, Waystar and Change Healthcare. Direct peers are Cohere Health, Anterior, Latitude Health and Infinx. AKASA is listed as an emerging player.
Does Case Health AI have an API?
Yes. Case Health AI offers API access to its platform and services. The Terms of Service explicitly grant a license to access and use the Services via APIs, with restrictions against reverse-engineering, reselling, or sublicensing without prior written consent. API credentials are mentioned in the Privacy Policy as part of Business and Account Information collected. The platform is designed for enterprise health plans to integrate AI agents for automating prior authorizations. Developer documentation is at www.casehealth.ai.
What industry is Case Health AI in?
Case Health AI's product category is Healthcare Prior Authorization Automation. Its primary akta.pro industry code is HLACACAA, Medical Billing & Coding Automation, with a secondary code of HLACAAAN, EHR Extensions, APIs, App Marketplaces & SMART-on-FHIR Apps. Its NAICS code is 524292 and its SIC code is 7372.