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Know Where You Stand. Know What to Fix.

Health plans manage performance across claims, utilization management, member services, provider networks, clinical programs, appeals, and finance, each with its own benchmarks, regulators, and stakeholders. Performance1™ unifies 14 operational modules into a single intelligence layer, powered by 7 AI analytics engines, benchmarked against NCQA, CAQH, CMS, and AMA standards, and connected to every Simplify Health Cloud™ product.
14+ Operational Modules Tracked
80+ Benchmarked KPIs with
Source Citation
7 AI Intelligence Engines Built In
CEO/COO/CIO Role-Based Executive
Intelligence Views
PA Data Dashboard

Key metrics

≥90%
Auto-Adjudication Target
Claims operations benchmark
≤10%
PA Denial Rate Benchmark
AMA 2024 standard
4+ Stars
MA Star Rating Target
Quality bonus threshold
≤85%
MLR Benchmark (Commercial)
ACA corridor compliance
≥80%
Electronic PA Submission
CMS-0057-F target by 2026

Health Plan Performance Intelligence, Unified Across Every Domain

Performance intelligence is only valuable when it connects to operational action. Performance1™ closes the loop between measurement and improvement.

Health plans are measured against dozens of benchmarks simultaneously: CMS Star Ratings, HEDIS measures, CAHPS scores, NCQA accreditation, state prompt pay compliance, PA turnaround mandates, and internal operational KPIs. Each domain has its own data source, its own regulator, and its own stakeholder expecting accountability.

Performance1™ is Simplify Healthcare’s health plan performance intelligence platform. It consolidates KPIs across 14 operational modules, benchmarks them against industry standards (NCQA, CAQH, CMS, AMA) and peer plans, surfaces actionable improvement opportunities with quantified financial impact, and connects performance signals directly to the operational products that can address them.

Where traditional reporting tools show you what happened, Performance1™ shows you what it means, how it compares, and what to do next, in real time, by LOB, and by region.

CMS-0057-F PA Mandates
14 Operational Modules
01
Claims and Payment Operations
End-to-end claims processing, adjudication accuracy, and payment workflow efficiency
02
Provider Management
Provider data quality, contracting, credentialing, and network adequacy across all markets
03
Call Center Operations
Provider and member call performance, first-call resolution, and digital deflection
04
Utilization and Clinical Management
Prior authorization, medical review, case management, and disease management programs
05
Appeals, Grievances, and Compliance
Regulatory timeliness, audit readiness, and prompt pay adherence across all operating states
06
Financial Performance and Executive Intelligence
MLR, admin cost, revenue forecasting, and role-based CEO, COO, and CIO views

14 Operational Modules, 80+ Benchmarked KPIs

Every KPI is sourced from authoritative benchmarks: CAQH Index, AMA Physician Survey, CMS Star Ratings methodology, NCQA HEDIS standards, and peer plan anonymized data. Performance1™ shows you where you stand today and what each metric improvement is worth in dollars, Stars, or compliance risk reduced.
Prior Authorization — Tabbed View

Claims operations determine both administrative cost and provider trust. Auto-adjudication rate, touchpoint count, and cycle time are the primary indicators of processing efficiency. Sources: CAQH Index 2025, industry payer benchmarks.

≥90%

Auto-Adjudication Rate

Top-quartile benchmark

≤1.5

Touchpoints per Claim

Manual labor drives 60–75% of cost

≤14 Days

Claims Cycle Time

Prompt pay compliance threshold

≥85%

First-Pass Resolution Rate

Reduces rework and provider calls

≤10%

Pend Rate

Each pend requires manual intervention

≤5%

Post-Adjudication Denial Rate

CMS and NAIC monitor denial trends

Provider management spans Provider Data Management, Contracting, Credentialing, and Network adequacy. All four directly influence MA Star Ratings, state contract renewals, call volume, and provider satisfaction. Sources: CAQH 2025, AMA 2024, CMS network adequacy standards, NCQA credentialing standards.

≥98%

Provider Data Accuracy Rate

CMS directory attestation required quarterly

≤30 Days

Credentialing Turnaround Time

NCQA standard; delays block network expansion

≤45 Days

Contract Cycle Time

High performers achieve 30-day cycles

≥98%

Prompt Pay Timeliness

Late payment drives network attrition

100%

Network Adequacy Compliance

CMS and state DOI require documentation

≥70%

Provider Portal Adoption

Low adoption drives fax-based PA and call volume

Call operations span Provider Call Operations and Member Call Operations. Both drive cost, satisfaction, and digital adoption. AI-powered call volume prediction and proactive deflection intelligence are built into Performance1™. Sources: CAQH 2025, CMS CAHPS benchmarks, NCQA 2025.

≥80%

First Call Resolution (FCR)

1% FCR gain = 1,500+ fewer calls/100K members

≤5.5 min

Member Average Handle Time

AI guidance reduces AHT by 15–25%

≤4.5 min

Provider Average Handle Time

Claims status and PA inquiry benchmark

≥40%

Call Deflection Rate

Each deflected call saves $8–18 vs. live agent

≥75%

CAHPS Overall Rating (9 or 10)

Direct MA Star Rating driver

≥55%

Digital Self-Service Adoption

Saves $15–25 per digitally resolved interaction

Utilization management encompasses prior authorization, medical necessity review, and concurrent review. CMS-0057-F (effective 2026) mandates electronic submission and specific turnaround timelines for MA and Medicaid plans. Sources: AMA 2024 PA Survey, CMS-0057-F, CAQH Index 2024.

≥60%

PA Auto-Approval Rate

Gold-card eligible providers

≤72 hrs

Urgent PA Turnaround

CMS-0057-F mandate (2026)

≤7 Days

Routine PA Turnaround

CMS-0057-F mandate (2026)

≤10%

PA Denial Rate

AMA: 31% say denials "often/always" occur

≥50%

Electronic PA Submission Rate

Only 35% fully electronic today (CAQH)

100%

Peer-to-Peer Qualification Rate

Regulatory and clinical risk if non-compliant

Clinical programs span Case Management for high-acuity members and Disease Management for chronic conditions including diabetes, CHF, COPD, and behavioral health. Both drive quality measure performance and medical cost reduction. Sources: CMSA 2024, NCQA Disease Management Standards, CMS HEDIS methodology.

≥75%

Case Management Enrollment Rate

Active CM reduces readmissions by 20–35%

≤12%

30-Day Hospital Readmission Rate

Each prevention saves $8K–25K per DRG

≥60%

Disease Management Engagement Rate

Multi-channel improves engagement by 25–40%

≥80% PDC

Medication Adherence (Chronic)

Top-weighted MA Star Rating measures

≥65%

Complex Case Resolution Rate (90-Day)

Primary outcome metric for CM ROI

Appeals and Grievances is one of the most compliance-intensive operational modules, combining member rights protection, regulatory timeliness mandates, and systematic error detection. High appeal overturn rates signal underlying adjudication issues. Sources: CMS MA Appeals and Grievances requirements, state Medicaid grievance standards, NAIC model act benchmarks.

100%

Grievance Response Timeliness

CMS: acknowledge within 24 hrs, resolve within 30 days

≤20%

Appeals Overturn Rate

High rates signal systematic adjudication errors

≤10 per 1K

Grievance Rate

Above threshold triggers state DOI review

≥98%

Prompt Pay Compliance

LPI penalties of 9–21% annually in 49 states

100%

CMS Reporting Accuracy

Late submissions carry civil monetary penalties

0

Material Audit Findings

Three consecutive findings can affect plan licensure

Financial workflows include MLR management, admin cost optimization, stop-loss recovery, and revenue forecasting. Admin cost ratios and PMPM trends are the primary indicators of operational efficiency. Sources: CMS MLR reporting, AHIP financial benchmarks, PwC Behind the Numbers 2025.

≤15% / 12%

Admin Cost Ratio (ALR)

Commercial / MA-Medicaid benchmark

≤6% YoY

Claims Cost PMPM Trend

Above 6% signals UM or network pricing gaps

80% / 85%

MLR Floor (Individual / Group)

ACA requires rebate if below threshold

≥95%

Stop-Loss Recovery Rate

Missed submissions leave employer money uncollected

Function-Level

Admin Cost PMPM by Function

Identifies above-market spend and automation ROI

Quality performance drives MA bonus payments, Medicaid contract competitiveness, and NCQA accreditation. Plans rated 4 stars or above receive quality bonus payments of $50–200+ PMPM above base rates. Sources: CMS Star Ratings methodology 2026, NCQA HEDIS 2025.

≥4.0 Stars

MA Star Rating (Overall)

Quality bonus threshold; 5-star = year-round marketing

≥50th Pctile

HEDIS Measure Compliance

Drives Stars, NCQA accreditation, Medicaid withhold

≥60%

Preventive Care Gaps Closed

Highest-ROI quality improvement lever

≥95%

Risk Adjustment Accuracy (HCC)

Each missed HCC = $1K–3K lost annual revenue

≥80% PDC

Medication Adherence Rate

3 of the highest-weighted Star measures

Built to Go Beyond Reporting

Performance1™ embeds AI intelligence directly into operational workflows. Rather than surfacing data after the fact, it identifies where performance is drifting, quantifies the financial impact, and points to the right intervention, before issues escalate into penalties or provider attrition.
Feature Strips

Intelligence Layer

01

Financial Impact
Simulation

Cost & Revenue

Models the cost and revenue impact of closing performance gaps across each operational module, benchmarked against industry data and peer payers.

02

Predictive Risk
Intelligence

Early Detection

Detects emerging risk across claims, provider network stability, call volume, and regulatory compliance before thresholds are breached, enabling proactive intervention.

03

Strategic Scenario
Modeling

ROI Projection

Simulates the operational and financial outcomes of strategic decisions, from network expansion to contract renegotiation, with projected ROI and break-even timelines.

The Right Intelligence for Every C-Suite Leader

Performance1™ delivers a tailored view to each executive, filtering 80+ KPIs to the metrics that matter most for their role, with forward-looking projections and benchmark context, not just historical data.
Persona Cards

Chief Executive Officer

Enterprise Performance and Strategic Positioning

A single view of where the plan leads and lags versus industry, with board-ready reporting, quality bonus revenue opportunity, and the highest-value improvement priorities ranked by financial impact.

Board Reporting Quality Bonus Strategic KPIs

Chief Operating Officer

Operations Command Center

A cross-functional operational view spanning claims, provider management, call operations, and utilization management, with active issue prioritization and recommended interventions.

Claims Ops UM Oversight Issue Prioritization

Chief Information Officer

Technology, Data, and Automation Intelligence

Focused on data quality, electronic transaction adoption, and automation performance, providing the metrics that govern digital transformation progress and platform health.

Data Quality EDI Adoption Automation KPIs

NCQA, CAQH, CMS, and AMA, All in One Place

Every benchmark in Performance1™ is sourced, cited, and updated annually. The Industry Benchmarks module gives operations, compliance, and finance teams a single reference for the standards they are measured against.

HITL PA Section
01

NCQA

HEDIS measures, accreditation standards, credentialing requirements, disease management program standards.

02

CAQH

Electronic transaction rates, provider data management, credentialing efficiency, administrative simplification index.

03

CMS

MA Star Ratings methodology, CMS-0057-F PA mandates, network adequacy standards, MLR reporting requirements.

04

AMA

Annual Physician Survey on PA burden, call operations, provider burnout metrics, and administrative simplification priorities.

ROI by Stakeholder

Performance intelligence is valuable only when it drives decisions. Performance1™ is built for the stakeholders who make those decisions.

CEO / COO

Enterprise Performance Visibility

  • Single dashboard across all seven performance domains, updated in real time
  • Peer benchmarking shows exactly where the plan leads and lags versus industry
  • Board-ready performance reporting generated automatically with trend context
  • Strategic improvement opportunities ranked by financial impact and feasibility
  • Early warning system for regulatory compliance drift before it becomes a violation

CMO / Medical Director

Quality and Clinical Performance

  • HEDIS measure performance with scenario modeling for Star Rating impact
  • PA auto-approval rate and denial rate trends by specialty and service type
  • Care gap closure tracking with member outreach prioritization by gap value
  • Risk adjustment accuracy reporting with HCC coding gap identification
  • Medication adherence monitoring mapped to highest-weight Star measures

CFO / Finance

Financial and Compliance Performance

  • MLR and ALR trend monitoring with regulatory threshold proximity alerts
  • Admin cost PMPM benchmarked by function to identify above-market spend
  • Prompt pay compliance tracking with LPI exposure quantification by state
  • Stop-loss recovery rate monitoring with threshold gap alerts for ASO plans
  • Star Rating revenue impact modeling: bonus payment sensitivity to quality metrics

VP Claims / Operations

Operational Efficiency

  • Auto-adjudication rate and pend rate by claim type, provider, and LOB
  • Claims cycle time performance versus prompt pay mandates by state
  • First-pass resolution rate trending with root-cause identification
  • Denial rate analysis with appeals overturn rate for systematic error detection
  • Operational cost PMPM benchmarking to identify automation ROI opportunities

VP Provider Relations

Network Performance

  • Provider satisfaction scores with trend and benchmark comparison
  • PA burden by provider, tracking volume, auto-approval rate, and gold-card eligibility
  • Network adequacy compliance monitoring across all geographic markets
  • Provider portal adoption and clean claim rate by practice and specialty
  • Payment timeliness performance preventing LPI exposure and network attrition

Compliance / Regulatory

Audit and Regulatory Readiness

  • Prompt pay compliance rates across all 49 states plus DC in real time
  • CMS-0057-F PA timeline adherence with proactive breach alerts
  • Grievance and appeals response timeliness versus CMS and state mandates
  • Audit-ready documentation generated automatically for each performance domain
  • Regulatory change tracking: benchmark updates as CMS and state rules evolve

See Where Your Plan Stands

Let's benchmark your plan across all 14 operational modules, run a live ROI simulation, and identify your highest-value improvement opportunities.