Reimagine Utilization Management
Compliance with CMS-0057 is the kickoff, not the end game.
Effective January 1, 2027, health plans must comply with the Fast Healthcare Interoperability Resources (FHIR)® APIs outlined in the CMS Final Rule for prior authorizations. Meeting the requirements of the Final Rule is an important step in the journey to transform electronic prior authorizations for payers and providers.
To guide you on this path, Availity offers nationwide connectivity and interoperability expertise, helping you meet the CMS mandate and drive automation across your organization.
One of the nation’s largest healthcare networks seamlessly connects payers, providers, and HITs to deliver unparalleled scale and reach.
Availity’s electronic prior authorization configuration maps bi-directional connectivity, including to delegated vendors, to give providers a single user interface for submissions.
Learn why compliance is only the first step toward transformation.
Reduce Administrative Burdens and Improve Provider Experience
Automate end-to-end electronic prior authorizations
For payers, utilization management is a time-consuming process in which clinicians must evaluate whether a prior auth case is medically necessary by manually reviewing complex, detailed medical policies against multiple pages of a patient’s medical records.
For providers, most prior authorization solutions don’t gather needed clinical data during submission, so authorization decisions are often delayed while waiting for records, creating friction and frustration.
Availity’s fully automated end-to-end electronic prior authorization solution extracts relevant clinical data at the time of auth submission, minimizing manual work for providers, reducing the administrative burden on payers, and helping ensure patients receive timely care.
Key outcomes include:
● Burden Reduction: 99% of submissions include completed attestations
● Touchless Resolution: 75% of auth requests recommended for auto approval
● Fast Resolution: Less than 20 second response time
Availity was featured in the 2024 KLAS case study and praised for our ability to unify payer-provider workflows, reduce friction, and support compliance with CMS interoperability mandates.
Learn why the Availity solution is a unique approach to lowering provider abrasion.
Deliver Trust and Transparency across Utilization Management
Modernizing UM requires AI-powered automation
Availity is working to modernize utilization management by streamlining the prior authorization process for payers and providers. We are doing this by reducing the time utilization management clinicians must spend on cases that do not require their expertise, while helping to quickly return a decision to the provider and patient.
Benefits of Availity's AI solution:
The submission is automatically evaluated against the most up-to-date clinical and policy information, allowing an approval recommendation to be rendered in near real time.
- Fast responses reduce provider friction and improve patient scheduling.
- Payers and providers have visibility into how the system’s decisions were evaluated against clear and transparent guidelines
Learn more about evaluating AI Solutions.
Are you ready to modernize utilization management?
Contact your Availity representative or submit a request.
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Availity is the trusted partner for organizations seeking to realize the greatest value from clinical, administrative, and financial data. Positioned at the nexus of provider, health plan, and consumer health information, Availity develops scalable, innovative solutions for healthcare data acquisition, standardization, transparency, automation, and exchange among health plans, providers, and technology partners. As one of the nation's largest health information networks, Availity facilitates billions of clinical, administrative, and financial transactions annually. Our suite of dynamic products, built on a powerful, intelligent platform, enables real-time collaboration for success in a competitive, value-based care environment.
