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Blogs

FHIR Prior Authorization: A Compliance Playbook for Health Plans

FHIR®-based prior authorization is becoming one of the most significant areas of regulatory focus for Medicare Advantage, Medicaid, and commercial payers. Requirements tied to the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) are accelerating the shift toward digital, structured, and highly coordinated exchange of clinical information.1 For managed care organizations and health plans, this shift affects technical infrastructure, data governance, and daily operations across utilization management, member services, and provider experience teams. Review the high-level playbook health plans should use to take a practical, readiness-oriented approach and move from awareness to execution.

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Blogs

Transformation at Scale: AI-Enhanced RCM & Utilization Management

Artificial intelligence is being used to bring structure and speed to administrative processes, helping plans make more informed decisions and reducing the manual burden across both RCM and UM. When deployed strategically, AI lets these two areas share intelligence, anticipate risk, and align on quality and efficiency targets, which changes how plans scale operations without sacrificing oversight. Examine how AI-enhanced RCM and UM can work in unison to deliver measurable transformation at scale and define the next era of payer performance.

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Tip Sheets

How to Prepare for CMS-0057-F

Ohio’s largest Medicaid managed care plan and leading birth coverage provider partnered to launch Healthy Beginnings at Home, a pilot program addressing the connection between housing instability and poor birth outcomes. To operationalize and evaluate this effort, Clearlink provided program development, evaluation support, and strategic advisory services. Backed by proven outcomes, the program expanded from a $200,000 pilot into a $15 million statewide investment, with national interest in replication.

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Blogs

D-SNP 2026: Navigating CMS’s New Enrollment Rules & Industry Preparedness

Contract Year 2026 brings a different operating reality for Dual Eligible Special Needs Plans (D-SNP). Monthly Special Enrollment Periods (SEPs) introduced in 2025 are now the market’s “new normal,” steering full-benefit duals toward integrated offerings and reshaping how plans compete outside AEP. Meanwhile, the Medicare Advantage Value Based Insurance Design (VBID) model sunsets after 2025, removing a lever many plans used for $0 drug copays and broad supplemental benefits. Layer on top the 2026 final rule’s protections around appeals/prior authorization, codified guardrails for Special Supplemental Benefits for the Chronically Ill (SSBCI), and automatic renewal for the Prescription Payment Plan, and you get a year defined by operational execution, not just benefit design.

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Blogs

Clinical Platform Transformation: Reducing Cost of Care with AI & Digital Health

Health plans and managed care organizations are dealing with unprecedented complexity heading into 2026. Rising costs, D-SNP regulations, and changing Medicaid policy are constantly reshaping how payers must operate. And at the same time, members expect better care coordination, faster responses, and truly digital-first engagement options while still receiving the value that only human interactions can provide. Review high-level tactics for clinical platform transformation and reducing cost of care via new technologies to build resilient, compliant, and scalable operations.

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Tip Sheets

2026 AI-Driven Utilization Management Strategies

The Centers for Medicare & Medicaid Services is advancing new rules that directly address the use of artificial intelligence in utilization management and prior authorization. These regulations put a spotlight on transparency, auditability, and fairness, shaping how payers, providers, and members experience UM. For managed care organizations, this is an opportunity to align operational efficiency with compliance while building trust through responsible AI integration. Learn more by requesting the free tip sheet.

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