Payors & Insurers

Prior Authorization Automation, Claims Intelligence & Population Analytics for Health Plans

We build prior authorization automation software, revenue cycle management platforms, FHIR-based payer interoperability, and population health analytics for health plans and managed care organizations - reducing administrative cost and meeting CMS-0057-F requirements.

Manual Prior Authorization Creating Care Delays

Fax-based submissions, phone-based status checks, and manual clinical review queues, creating 3 to 5 day approval cycles. 93% of physicians report care delays due to prior authorization (AMA data).

Member Risk Data That Cannot Drive Outreach

Claims history, pharmacy data, and care management notes across lines of business, with no unified analytics layer to risk-stratify members and trigger proactive outreach before high-cost events occur.

Disconnected Claims Increasing Denial Rates

Claims systems and utilization management platforms that cannot exchange data in real time, producing coding inconsistencies and authorization mismatches that generate first-pass denial rates requiring expensive rework.

CMS Interoperability Mandates Requiring FHIR

CMS-0057-F requires covered payors to implement FHIR R4 Patient Access, Provider Access, and Payor-to-Payor APIs. Payors without a FHIR roadmap face CMS compliance risk and regulatory deadline pressure.

01What we build

What We Build for Health Plans and Managed Care Organizations

Four service areas from prior authorization automation and claims intelligence through population analytics and FHIR regulatory compliance.

Prior Authorization Automation, Da Vinci CRD, DTR & PAS

Full Da Vinci workflow: Coverage Requirements Discovery (CRD) surfaces payor requirements at EHR order entry; Documentation Templates and Rules (DTR) assembles clinical documentation automatically; Prior Authorization Support (PAS) handles X12 278 submission and response, with denial tracking and appeal workflow built in.

CRD: payor requirements surfaced at Epic, Athenahealth, eClinicalWorks order entry before the order is placed
DTR: documentation assembled from EHR structured data, diagnosis, procedure codes, clinical notes, prior results
PAS: X12 278 request and response with payor-specific rule configuration across your entire payor mix

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Revenue Cycle Management & Claims Intelligence

RCM platform integration for payors, Quadex and CareViso for claims automation, provider data management for eligibility verification, and claims analytics for denial pattern identification and clean claim rate optimization.

Quadex and CareViso: claims processing automation, remittance processing, and denial workflow management
Clean claim rate optimization: scrubbing rules tuned to payor-specific requirements, reducing first-pass denials
Underpayment identification and contract compliance monitoring integrated with adjudication data

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Population Health Analytics & Member Risk Stratification

Unified member analytics combining claims, pharmacy, care management, and SDOH data, with HCC risk scoring, Star Rating dashboards, HEDIS measure calculation, and automated care management outreach triggers.

HCC risk adjustment: prospective risk scoring, risk trending, and hierarchical condition category gap identification
Star Rating and HEDIS: quality measure performance, care gap prevalence, and member-level drill-down
Automated outreach: triggers on risk tier change, care gap identification, and care transition events

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FHIR R4 Payor Interoperability, CMS-0057-F Compliance

FHIR R4 API implementation for CMS Interoperability Final Rule compliance, Patient Access, Provider Access, and Payor-to-Payor APIs, using a FHIR facade over existing adjudication systems so compliance is achieved without replacing legacy infrastructure.

Patient Access API: ExplanationOfBenefit, Coverage, MedicationRequest, and clinical documents accessible to members
Provider Access API: member data available to treating providers for care coordination, no member portal required
Payor-to-Payor API: clinical data and prior authorizations exchanged at member transitions per Da Vinci PDex IG

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02Outcomes

What Health Plans and Managed Care Organizations Get Back

✓

Prior auth cycle time reduced 60 to 80 percent, from days to same-day for standard procedures

✓

HCC, Star Rating, and care gap analytics surfaced in real time to care management teams

✓

CMS-0057-F Patient Access, Provider Access, and Payor-to-Payor FHIR APIs implemented on schedule

✓

First-pass denial rates reduced through upstream claims scrubbing and documentation automation

✓

Provider abrasion reduced through faster authorization cycle times and documented payor rules

✓

Medical loss ratio improved through proactive high-risk member outreach before high-cost events

03Case study

Proof From Payor Engagements

Population Health Management at Scale

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Frequently Asked Questions

What does the CMS Interoperability and Prior Authorization Final Rule require from payors?

CMS-0057-F (finalized January 2024) requires covered payors, Medicare Advantage, Medicaid managed care, CHIP, and QHP issuers, to implement: a Patient Access API (already in effect) for member access to claims, formulary, and prior authorization data; a Provider Access API and Payor-to-Payor API (required January 1, 2027); and electronic prior authorization using FHIR-based Da Vinci PAS (required January 1, 2027). Non-compliance can result in CMS corrective action requirements and public reporting.

How do you integrate FHIR prior authorization with a legacy adjudication system?

We deploy a FHIR facade in front of the legacy adjudication system, a FHIR server layer that translates incoming Da Vinci PAS FHIR requests into the adjudication system's native format using MIRTH Connect or a custom transformation service, and returns adjudication responses as FHIR ClaimResponse resources. The legacy system requires no modification; it continues processing requests in its existing format while the FHIR facade handles external API compliance.

How is population health management for payors different from clinical population health management?

Payor population health runs on claims data, adjudicated claims, pharmacy, and lab claims, rather than the clinical EHR record, which payors do not have direct access to without consent. The analytics focus is risk and quality management: HCC risk scoring, Star Rating performance, and HEDIS measure tracking, not clinical care delivery. Clinical context from FHIR Patient Access API data improves risk model accuracy but the core platform operates on the claims data payors already hold.

How do you measure the ROI of prior authorization automation?

Five dimensions: administrative cost reduction (manual authorization costs $30 to $80 per request, automation reduces this by 60 to 80 percent); cycle time improvement (3 to 5 business day approvals reduced to same-day); provider satisfaction improvement (prior auth burden is the leading driver of provider network dissatisfaction); denial rate reduction (documentation automation eliminates the documentation errors that drive first-pass denials); and downstream quality improvement (faster approvals for oncology and cardiology reduce care delays that drive high-cost events and medical loss ratio increase).

04Related solutions

Explore the Underlying Solutions

Ready to Automate Prior Authorization and Modernize Your Payor Platform?

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