Prior Authorization

Review burden is the economic problem in prior authorization.

Prior authorization already costs clinical time, turnaround pressure, and exception work. AI can remove routine steps. It can also grow full review if the plan cannot tell a well-supported case from a risky one.

Start with volume, full-review share, time, and loaded cost. Then talk about review burden, economics, AI maturity, and decision control.

Model review economics Evaluate the workflow Discuss a prior-auth workflow
Prior authorization clinical review context
Start with review burden.Then economics, AI maturity, and Decision Control.
The problem

PA work is heavy before AI. AI can make the economics worse if full review grows with volume.

Intake, extraction, criteria, clinical review, and downstream notices already stack. Automation helps only when full review, exceptions, and rework do not take the return.

Problem

Prior authorization burden

Cases pile up. Turnaround targets get harder. Clinical reviewers spend time on routine work and hard exceptions alike.

Cost

Review and exception cost

Every full review has loaded cost. Avoidable full reviews erase automation savings before the model score looks wrong.

Better state

Right review at the right time

Supported work moves with less friction. Hard cases get clinical attention. Leaders can explain why a payer action was allowed.

Review economics

Use your volume. See what a lower full-review share could mean.

Enter annual authorization volume, the share that gets full review today, average review time, and loaded reviewer cost. Scenarios show 5%, 10%, 20%, and 30% reductions in full reviews. These are Economic scenarios for planning, not realized outcomes.

Review-burden model

Enter your volume and review burden. Results stay on this page until you continue the conversation.

Individual circumstances matterCMS guidance says AI or algorithms may assist Medicare Advantage coverage determinations, but the organization remains responsible for compliance and individual patient circumstances must be considered; specified adverse decisions cannot rest on the algorithm alone.CMS guidance
Technology + clinician reviewCMS's 2026 WISeR model explicitly combines enhanced technology with human clinical review, and appropriately licensed clinicians determine recommendations for non-payment.CMS WISeR model
CMS context

CMS-0057-F timing is already an operating priority for impacted payers.

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.

2026 process

Decision timeframes, denial reasons, and metrics

Impacted payers generally must meet process rules starting January 1, 2026, including decision timeframes for most payer types, specific denial reasons, and public metrics (initial metrics by March 31, 2026 per CMS).

2027 APIs

Patient Access, Provider Access, Payer-to-Payer, Prior Authorization APIs

Major API work is generally due beginning January 1, 2027. Timing varies by payer type.

Operating bridge

Electronic PA is not the same as operating value

Data exchange helps. Plans still need the right review posture and a clear basis for consequential actions.

CMS fact sheet: CMS-0057-F · Health Plans

Decision Control

Proposed application: Decision Control for prior authorization

When AI influence builds across intake, extraction, criteria, and clinical review before a payer action, Decision Control applies selective control: more AI work where the case supports it, tighter human handling where consequence and uncertainty rise. It helps set case-level responsibility, direct review when needed, protect automation value, and keep a clear record.

Case-to-case responsibility

AI authority can change with the case, evidence, and consequence.

Direct review when needed

Send the right cases for extra clinical review instead of reviewing everything the same way.

Protect automation value

Keep human handling where it is structurally required, not only where current controls cannot discriminate.

Keep a clear record

Preserve a basis for why a consequential payer action was allowed.

Public handling language: Proceed, Verify, Review, Hold or escalate. Explore Decision Control Plane

Next step

Evaluate the workflow before AI takes on more PA responsibility.

Bring one prior-auth workflow. We will recommend Initiative Review, Build, Pilot, Decision Control Assessment, Decision Control Plane, or no engagement.

Decision Control Assessment / DCP

DCA starts at $30,000. DCP is scoped.

See DCA

Evaluate the workflow

Bring review burden, economics, and the Decision Control question. Start with a Decision Control Assessment when AI already shapes consequential PA actions.

Evaluate the workflow Discuss a prior-auth workflow
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