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Blogs

AI-Enabled Utilization Management: The Future of Prior Authorization

According to an AMA survey, 61 percent of physicians reported concern that AI-driven PA is increasing denials and will override sound clinical judgment. AI use in prior authorization is at a turning point. This is a moment when health plans need to be clear about their strategy and make cultural and operational shifts across the organization. The next generation of utilization management will be defined not by which health plans deploy the most algorithms, but by which organizations build AI-enabled programs grounded in clinical integrity, effective governance, and interoperability infrastructure designed to last.

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Blogs

NCQA’s New Era: Health Outcomes & Community-Focused Care Accreditation

In January, Health Equity Accreditation became Health Outcomes Accreditation, and Health Equity Accreditation Plus became Community-Focused Care Accreditation.¹ The updated names arrive ahead of Standards Year 2026, which will introduce expanded content focused on sustained outcome improvement and deeper community alignment.¹ For health plans and Medicaid MCOs, this change reflects a reframing of how NCQA expects organizations to demonstrate accountability. The focus is moving from documenting equity activities to proving measurable, long-term impact on outcomes and community health. Understand how NCQA’s renamed accreditations and expanded 2026 standards reshape expectations for health plans and managed care organizations.

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Blogs

From Regulation to Reckoning: Decoding CMS Prior Authorization in 2026

CMS expects tangible operational change under the authorities and commitments already in place, rather than prolonged debate over additional regulatory interventions. Klomp acknowledged that CMS has limited additional regulatory authority across Medicare, Medicaid, and commercial markets.1 The framework has been set. The focus now rests on implementation and execution. Are prior authorization requirements making a difference?

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Blogs

How Automation Is Reshaping Utilization Management & Prior Auth Workflows

Prior authorization has been a central component of utilization management for decades. Health plans rely on the process to evaluate medical necessity, manage costs, and maintain appropriate care delivery. At the same time, the administrative burden tied to prior authorization has grown steadily as documentation requirements, clinical criteria, and regulatory expectations have expanded. Within utilization management programs, automation is reshaping case routing, staffing models, clinical review processes, and governance practices. For health plans with established UM operations, the primary consideration today is how automation fits into the broader operating model for prior authorization.

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Blogs

CMS-0057-F & Prior Authorization: Operating Under the New Standard

For managed care organizations, CMS-0057-F is now embedded in day-to-day operations. The initial compliance requirements tied to prior authorization timeframes, denial specificity, and public reporting are in effect. The next phase, including required FHIR-based APIs, is approaching quickly. Is your team’s performance stable, defensible, and sustainable? Operating under this new standard requires more than technical compliance. It demands operational discipline across clinical, administrative, and data functions.

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Blogs

AI-Enabled Prior Authorization: Balancing Automation & Clinical Judgment

Health plans are already implementing AI-driven workflows to process requests faster, reduce administrative workload, and improve consistency in utilization management. But how far should automation go? Rather than treating AI as a replacement for clinicians, these systems use automation to handle predictable tasks while reserving human expertise for complex medical decisions. When implemented thoughtfully, this hybrid model can improve efficiency while protecting the clinical integrity of the authorization process.

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