Utilization Management

Streamline Workflows. Accelerate Decisions. Stay CMS-Compliant.

Utilization Management – Optimizing Medical Expenses with Smarter Prior Authorizations

In today’s healthcare landscape, effectively managing medical expenses is more challenging than ever. Prior authorization processes—essential for controlling unnecessary spending—often create bottlenecks, leading to frustration for providers, patients, and payers alike. Adding to this complexity is the CMS-0057-F mandate, which requires the adoption of electronic prior authorization (ePA) and HL7® FHIR® APIs to enhance transparency and efficiency.

The Challenges in Prior Authorization

Cumbersome Prior Authorization Workflows

Traditional workflows rely on manual interventions, disconnected systems, and excessive documentation, leading to inefficiencies and delays in care delivery.

High Denial Rates and Poor Visibility

Incomplete or incorrect documentation often results in Prior Authorization denials, increasing administrative burdens while impacting provider satisfaction and member outcomes.

Navigating Regulatory Mandates

The CMS-0057-F rule demands integration of FHIR-enabled APIs to modernize prior authorizations, leaving health plans scrambling to implement compliant systems by the mandated deadlines.

Balancing Cost Control with Member Satisfaction

Health plans must contain costs while ensuring members receive timely & appropriate care—a delicate balance often disrupted by inefficiencies in utilization management.

How We Solve It

End-to-End Automation for Prior Authorization

Real-Time Coverage & Eligibility Checks

Providers can check in real-time whether a specific member is eligible and if the procedure is covered under their policy, reducing delays, inaccurate documentation and PA submissions and ultimately reducing denials.

End-to-End Integration

Integrate the FHIR-based prior authorization API with 3rd party utilization management partners & vendors to maintain business as usual while creating an end-to-end electronic prior authorization process.

Streamlined Workflows

Eliminate manual steps by creating bi-directional data exchanges between payers and providers, reducing manual documentation, increasing auto-approvals and providing denial reasons for continuous improvement.

Compliance with CMS-0057-F Mandate

FHIR-Enabled APIs

Implement APIs such as the Coverage Requirements Discovery (CRD), Documentation Templates and Rules (DTR) and Prior Authorization Support (PAS) APIs to align with CMS requirements, facilitating real-time information exchange between payers & providers for data-driven decisioning.

Developer Portal for Easy Integration

Support third-party adoption of FHIR APIs with a secure, developer-friendly interface that accelerates implementation timelines.

Actionable Insights to Minimize Denials

Comprehensive Data Processing

Leverage normalized data from across the Payer and Provider environments to ensure accuracy and completeness, reducing the chances of errors that lead to denials, while automating the decisioning process.

Analytics & Reporting

Track key metrics around Prior Auth API usage, PA volumes, approvals, denials and more!

Learn more about streamlining prior authorizations

Why It Matters

By addressing these pain points, health plans can

Enhance Member & Provider Experiences

Minimize delays in care delivery and improve health outcomes.

Reduce Denial Rates

Improve provider satisfaction and member access to care.

Ensure CMS Compliance

Avoid penalties and improve operational efficiency.

Optimize Medical Costs

Gain better control over medical loss ratios (MLR) through smarter, automated processes.

Discover how we tackle other critical challenges for Health Plans

Explore More Problems We Solve

CMS Interoperability

Meet interoperability mandates and regulatory requirements.

Quality Improvement

Drive better Star Ratings and meet HEDIS benchmarks.

Risk Adjustment Precision

Optimize reimbursements through data-driven insights.

Reimagine Prior Authorization Today

Turn prior authorization into a streamlined, value-driven process that benefits providers, members, and Payer bottom lines.

Contact Us to Learn More

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