Evidence looked acceptable in a limited run. Ownership, economics, workflow fit, and scale criteria are still unresolved.
Health plans · Payers · Insurance
Health plan AI that reaches production value, not just another pilot.
GNS-AI helps health plans design initiatives, build and redesign payer workflows, evaluate pilots before scale, and expand useful AI work where the operating case is clear. Control capabilities are available when AI shapes consequential determinations.
Chief AI, CIO, CTO, data and analytics leadership, utilization management, prior authorization, claims and payment operations, provider and network operations, member operations, Responsible AI, governance, risk, and compliance.
Built for payer operations.Care delivery organizations: see the Healthcare page.
The operating problem
AI investment rises. Workflows stay expensive. Pilots stall. Review stays heavy.
Health plans are investing in AI and automation, but value is lost when workflows remain expensive, pilots fail to scale, human review remains heavy, or the organization cannot confidently expand the amount of useful work AI takes on.
Exceptions, rework, and review absorb the expected savings. Throughput stays flat.
Leadership wants more AI capacity, or will not approve it, without a clearer decision trail and control story.
Why now
CMS-0057-F is already an operating priority for impacted payers.
CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) sets process requirements that generally began January 1, 2026, and API requirements that generally begin January 1, 2027. Exact dates vary by payer type. This is timing context, not legal advice.
2026 process provisions
Decision timeframes, denial reasons, and metrics
Impacted payers generally must meet certain operational prior authorization provisions beginning January 1, 2026, including decision timeframes for most payer types, specific denial reasons, and public prior authorization metrics (initial metrics by March 31, 2026 per CMS).
2027 API requirements
Patient Access, Provider Access, Payer-to-Payer, Prior Authorization APIs
Major API development and enhancement requirements are generally due beginning January 1, 2027, with timing that varies for MA, Medicaid and CHIP FFS, managed care, and QHP issuers on FFEs.
The business bridge
Electronic PA is not the same as operating value
As prior authorization becomes more electronic and automated, health plans still have to determine where automation removes work, where human review remains necessary, and which AI investments create measurable operating value.
CMS fact sheet: CMS-0057-F · Prior authorization application
Payer workflows
Where health-plan AI work shows up in the operating system.
Examples of relevant work. Not claims of completed client engagements in each area.
Flagship wedge
Prior authorization
Automation, review burden, decision timeframes, and scale readiness in PA operations.
Prior authorization pageAdjacent operations
UM, appeals, claims, payment integrity
Utilization management, appeals, claims operations, payment integrity, and coverage workflows.
Network and member
Provider, network, and member operations
Provider data and network operations, member access and service, and AI-assisted operational workflows.
How to buy
Design. Build. Prove. Scale.
Clear commercial paths for health-plan buyers. Control is available where the workflow warrants it, not as the default first purchase.
Should we do it?
AI Initiative Review
$3,500 fixed · 5 business days. Pressure-test whether a payer initiative is worth pursuing before a larger build.
See the Initiative ReviewCan we make it work?
Scoped AI Build
Implement, redesign, integrate, or improve a defined payer workflow when requirements are clear enough to build.
See Scoped AI BuildDid it actually work?
Pilot Efficacy & Scale Readiness
Evidence for go / no-go / narrow before a scale decision on a payer pilot or early deployment.
See Pilot EvaluationWorking session
Workshops
Strategy, use-case prioritization, pilot evaluation, Responsible AI, and operating alignment formats under the same doors.
See workshopsWhen control is the question
Decision Control Assessment
Deeper evaluation of one consequential workflow before additional control investment.
See the AssessmentWhen persistent control is warranted
Decision Control Plane
A subsequent option for runtime decision-level control, not the default first purchase.
See DCPRelated markets
Health plans are distinct from care delivery and federal work.
Provider and health-system buyers should use the Healthcare page. Agency buyers should use Federal & Public Sector.
Next step
Have one health-plan AI workflow where value is getting stuck?
Bring an initiative that is unclear, a workflow to automate, a pilot that has not proven its value, or a process where review burden is eroding the economics. The fit call routes to the smallest appropriate paid engagement, or to no engagement.