COO, VP Ops, CIO, CAIO, CDO, CMO, and UM / PA / claims leaders feel the same pressure in different places: too many AI bets, automation that still leaves labor, data that blocks the workflow, and AI that shapes consequential payer actions.
GNS-AI helps health plans Prioritize, Design, Build, Prove, and Scale what works, with Decision Control when AI shapes important actions.
Potential value from automation is reduced by retained full review, exceptions, rework, delay, appeals, and failure exposure. Decision Control matters when AI shapes consequential coverage or payment actions, but the economic question applies across Design, Build, Prove, and Scale.
Start with the stuck situation. Then pick the engagement that matches.
Ideas pile up across PA, UM, claims, payment integrity, provider ops, and member ops. Capacity does not. Leadership needs a clear order of attack before more build spend.
$7,500 fixed fee | 7 business days.
Prioritize our AI opportunitiesHeadcount, backlog, exceptions, and turnaround still move with volume. Savings stall when full review and rework grow with automation.
Stage-appropriate next step: Scoped Build, workflow automation, or Pilot Efficacy & Scale Readiness.
AI cannot finish work when the data is fragmented, late, or hard to use across core systems. Integration and interoperability become the constraint.
Route through data / interop design and Scoped Build. Denodo is a verified technology partnership for data virtualization and semantic access when that fit is right.
Coverage, UM, PA, and claims actions still need the right review at the right time, with a clear basis for why AI was allowed to act.
Start with a Decision Control Assessment. Persistent runtime control sits on the Decision Control Plane. Prior authorization is a proposed application.
Case-appropriate AI authority. Selective, substantive human review.
What happened. ProPublica reported that Cigna's PxDx system supported rapid claim denials with limited clinician time per case. Cigna has stated that physicians review claims and that the reporting mischaracterized its process.
Why it matters. Named human review is not the same as substantive review with enough context and real decision authority.
Where Decision Control could intervene. This is a point where Decision Control is designed to intervene when review is named but may not be substantive for the case at hand.
What different handling could have occurred. Cases that look routine on paper could have been routed to qualified review with enough context and authority before a denial posted.
What happened. Plaintiffs allege that UnitedHealth and naviHealth used nH Predict to cut off post-acute care in ways that overrode treating clinicians. The company states the tool guides care and clinicians make medical necessity determinations.
Why it matters. Leaders need an operational answer for how much authority an AI-shaped conclusion should receive in the particular case.
Where Decision Control could intervene. This is a point where Decision Control is designed to intervene when an AI-shaped recommendation begins to carry practical authority over care.
What different handling could have occurred. High-consequence recommendations could have been held or escalated for qualified clinical judgment before care was cut off.
Selective automation only works when supported work can move, and when required review is substantive enough that a qualified person can change the outcome before the consequential action moves forward. Decision Control is the layer designed to decide case by case whether the next step is Proceed, Verify, Qualified Review, or Hold or Escalate.
CMS-0057-F is a federal rule on prior authorization and data sharing. Process rules generally began January 1, 2026. API rules generally begin January 1, 2027. Exact dates vary by payer type. This is timing context, not legal advice.
Impacted payers generally must meet prior authorization process rules starting January 1, 2026. That includes decision timeframes for most payer types, specific denial reasons, and public prior authorization metrics (initial metrics by March 31, 2026 per CMS).
Major API build and upgrade work is generally due beginning January 1, 2027. Timing varies for Medicare Advantage, Medicaid and CHIP, managed care, and QHP issuers on FFEs.
Electronic prior authorization helps exchange data. Plans still must decide where automation removes work, where clinical review stays needed, and which AI investments pay off.
CMS fact sheet: CMS-0057-F · Prior authorization path · PA economics calculator
Use these when the stuck situation above already points here.
$7,500 fixed fee | 7 business days. Rank which AI opportunities deserve serious investment.
Prioritize our AI opportunities$3,500 fixed · 5 business days. Pressure-test one AI, automation, workflow, or data initiative before more capital is spent.
See Initiative ReviewClear scope, integration, and handoff when the operating problem is clear enough to deliver.
See Scoped BuildProve whether a pilot created enough real-world value to justify scale.
See Pilot Evaluation3-4 weeks · Starts at $30,000 · Typical $30,000-$45,000. Evaluate one consequential workflow before persistent Decision Control.
See DCAPersistent runtime Decision Control for consequential AI workflows. Scoped.
See DCPA 30-minute fit call confirms Prioritization, Initiative Review, Build, Pilot, Decision Control Assessment, Decision Control Plane, or no engagement.