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Eliminate the PA Bottleneck.

Physicians spend 13 hours per week on prior authorization. 89% say it contributes to burnout. PriorAuth1™ applies agentic AI to automate PA decisions, enforce gold-card programs, and meet CMS-0057-F FHIR timelines, all while keeping humans in the loop for every denial.
60%+ PA Auto-Approval Target Rate
72-hr Expedited /
7-day Routine CMS-0057-F Compliance
39 PAs Per Physician Per Week
HITL All Denials Require Human Attestation
PA Data Dashboard

Key metrics

89%
Burnout link
PA cited as burnout contributor
31%
Denial rate
Often or always denied
35%
Electronic PA
Fully electronic today (CAQH 2024)
13h
Weekly burden
Per physician across all payers
15%
P2P qualified
Appropriate specialist peer

Prior Authorization,
Transformed by AI

Health plans that automate PA in 2026 will build provider trust, reduce burnout-driven attrition, and lower administrative cost, all at once.

Prior authorization is the single biggest friction point between health plans and their provider networks. Physicians complete 39 PAs per week on average, spending 13 hours that should be spent on patient care. Health plan staff spend equivalent time on manual clinical reviews that AI can handle in seconds.

PriorAuth1™ is Simplify Healthcare’s agentic AI solution for end-to-end prior authorization automation. It applies clinical criteria logic, historical precedent, and gold-card program rules to auto-approve eligible requests, escalating only those cases requiring genuine clinical judgment to qualified human reviewers.

The result: faster decisions for providers and members, lower administrative cost for health plans, and a defensible, auditable PA process that satisfies CMS-0057-F requirements, gold-card mandates, and state AI legislation simultaneously.

CMS-0057-F PA Mandates
CMS-0057-F PA Mandates — Effective January 2026
01
FHIR-based PA API
Required for all MA and Medicaid managed care plans
02
Expedited decisions
72-hour turnaround for urgent clinical needs
03
Routine decisions
7-calendar-day maximum turnaround required
04
Denial rationale via API
Specific clinical rationale required on every denial
05
Gold-card provisions
High-performing providers exempt from repeat PAs
06
Audit trail requirements
Every PA decision must be explainable and documented
Compliance CMS-0057-F Colorado AI Act HITL Governance

Prior Authorization Is Breaking Provider Relationships

The PA burden is not just an administrative inconvenience. It is a systemic drain on provider trust, member outcomes, and health plan operating cost.
Prior Authorization Challenges
13 hrs Per physician per week on PA

Physician burnout at scale

Physicians complete 39 PAs per week across all payers. 89% say PA contributes to burnout, and 40% have staff whose primary role is obtaining prior authorizations — directly impacting provider retention and network stability.

31% Say PAs are often or always denied

Denial rates eroding trust

Nearly a third of physicians report that PA requests are often or always denied, even when clinically appropriate. Only 16% see PA reduction commitments actually materialize, destroying credibility with provider networks.

35% Of medical PAs are fully electronic

Paper-based process in a digital world

Only 35% of medical PAs are fully electronic today (CAQH 2024). Fax, phone, and web portals dominate — creating processing delays, data loss, and compliance liability as CMS mandates FHIR-based submission by 2026.

15% Peer-to-peer with qualified specialist

Peer review quality crisis

CMS and AMA mandate peer-to-peer reviews be conducted by appropriately qualified specialists. Only 15% of physicians report they often or always speak to an appropriate peer, creating clinical and regulatory risk for health plans.

↑ $B Annual admin cost from manual PA

Administrative cost compounding

Manual PA processing requires clinical reviewers, administrative coordinators, peer-to-peer scheduling, and appeals management. Costs compound as volume grows, with no efficiency improvement from traditional approaches.

CMS Mandate effective 2026

Compliance deadline now in view

CMS-0057-F requires MA and Medicaid plans to implement FHIR-based PA APIs, meet 72-hour expedited and 7-day routine timelines, and transmit specific denial reasons electronically. Non-compliance carries regulatory and audit risk.

PA Performance Metrics: Where Health Plans Are Measured

The AMA, CMS, and CAQH define the metrics by which health plan PA performance is evaluated by providers, regulators, and accreditation bodies. PriorAuth1™ is designed to move every metric to benchmark.
PA Performance Metrics

01 — Auto-approval

PA auto-approval rate

% of PA requests approved without manual clinical review

Gold-card programs exempt high-performing providers. Only 16% of physicians see announced PA reductions actually materialize.

≥60%
benchmark

02 — Turnaround

PA decision turnaround

Average hours from PA submission to decision

CMS mandate effective 2026: MA and Medicaid plans must meet these timelines. Violations carry audit and regulatory risk.

≤72hr
urgent ≤7 days routine

03 — Denial rate

PA denial rate

% of PA requests denied

31% of physicians say PAs are "often or always" denied. High denial rates drive provider dissatisfaction, appeals volume, and network attrition.

≤10%
benchmark

04 — Electronic

PA electronic submission rate

% of PAs submitted and processed via X12 278 or FHIR API

Only 35% of medical PAs are fully electronic today (CAQH 2024). CMS-0057-F mandates FHIR-based PA by 2026.

≥50%
benchmark

05 — Volume

PA volume per provider

Average PAs required per physician per week from this plan

Physicians complete 39 PAs per week across all payers, spending 13 hours. 89% say PA contributes to burnout.

39/wk
trending ↓

06 — Peer review

Peer-to-peer qualification rate

% of peer-to-peer reviews conducted by an appropriately qualified specialist

Only 15% of physicians say they "often or always" speak to an appropriate peer (AMA). Regulatory and clinical risk for non-compliance.

100%
benchmark

Six Capabilities That Automate the PA Lifecycle

PriorAuth1™ covers every stage of the prior authorization process, from submission to decision to appeals, with AI at each step and humans in the loop for every adverse outcome.
PA Management Capabilities

AI-Powered Auto-Approval Engine

Applies clinical criteria logic, plan-specific medical policies, and gold-card program rules to approve eligible PA requests instantly, without manual review. Benchmarks every request against CMS InterQual and plan-specific criteria simultaneously.

InterQual Logic Gold Card FHIR API

Gold-Card Program Management

Automatically identifies high-performing providers meeting exemption thresholds, manages gold-card status lifecycle (award, monitor, revoke), and exempts qualifying providers from routine PA requirements, reducing volume and improving provider satisfaction.

Provider Scoring Auto-Exempt Lifecycle Mgmt

FHIR-Native Electronic Submission

Receives PA requests via X12 278, FHIR R4 PAS IG, or legacy fax-to-digital conversion. Routes all incoming requests to the AI triage engine within minutes of receipt, eliminating manual data entry and submission delays.

X12 278 FHIR R4 CMS-0057-F

HITL Clinical Review Workflow

Cases requiring clinical judgment are escalated to qualified reviewers with full clinical context, AI analysis, and criteria reference. All denials require human attestation before transmission. Peer-to-peer scheduling is matched by specialty, satisfying AMA and CMS qualification requirements.

Specialty Matching Attestation Required Audit Trail

Real-Time PA Analytics Dashboard

Tracks auto-approval rates, decision turnaround, denial rates, and electronic submission rates by provider, service type, LOB, and time period. Flags approaching CMS deadline breaches before they occur, enabling proactive intervention rather than reactive correction.

Turnaround Monitoring Denial Analytics CMS Reporting

Appeals and Reconsideration AI

Applies precedent-based reasoning to PA appeals, identifying cases where initial denial criteria were misapplied and flagging for expedited reconsideration. Generates explainable rationale for upheld denials that satisfies member and provider appeal rights.

Precedent Reasoning Explainable AI Appeal Rights

Human-in-the-Loop Engineered for PA

Prior authorization denials carry member harm risk and regulatory consequences. PriorAuth1™ builds HITL governance into every denial pathway, not as an afterthought, but as the foundational design principle.

HITL PA Section
01

No autonomous denials

AI recommendations are never transmitted without human review and attestation by a qualified clinical reviewer. Full AI reasoning and precedent surfaced for every decision.

02

Qualified peer-to-peer matching

Matches providers by specialty and subspecialty per CMS and AMA requirements. Scheduling fully automated — outcomes captured for audit.

03

Full audit trail

Every PA decision generates a timestamped record — criteria, AI confidence, reviewer identity, clinical rationale. Satisfies state transparency and CMS requirements.

CMS-0057-F: The Compliance Architecture Is the Product

CMS-0057-F requires FHIR-based PA APIs, specific denial reason transmission, and adherence to expedited and routine decision timelines, effective for plan years beginning 2026. PriorAuth1™ is architected from the ground up to satisfy these requirements, not retrofitted.

FHIR-based PA APIs — native, not patched in

Specific denial reason transmission per CMS spec

Expedited & routine decision timeline enforcement

Audit trails satisfying state transparency legislation

ROI by Stakeholder

PriorAuth1™ delivers measurable value across every function that touches prior authorization, from clinical operations to provider relations to finance.

Clinical / Medical Director

Clinical quality and efficiency

  • Auto-approval rate targeting 60%+, reducing manual clinical review volume by more than half
  • Qualified peer-to-peer matching by specialty: 100% compliance with CMS and AMA standards
  • AI-assisted clinical criteria application: consistent, auditable, defensible decisions
  • Denial rate monitoring with real-time alerts when rates exceed plan benchmarks
  • Appeals analysis identifies systematic criteria misapplication for policy correction

Provider Relations / Network

Provider trust and retention

  • Gold-card programs materialize: high-performing providers see real PA exemptions, not announcements
  • 72-hour expedited and 7-day routine decisions met consistently, tracked in real time
  • Provider-facing PA status transparency via Portal1™ integration: no follow-up calls
  • Electronic submission improvement: move from 35% to 80%+ FHIR-based submission
  • Peer-to-peer quality improvement reduces provider complaints and network attrition risk

Finance / CFO Office

Cost and compliance

  • 60%+ auto-approval rate reduces clinical reviewer headcount requirements significantly
  • CMS-0057-F compliance avoids regulatory penalties and audit exposure
  • Appeals volume reduction as consistent, criteria-based decisions lower unnecessary denials
  • Administrative coordinator hours redirected from PA chasing to higher-value work
  • Star Rating protection: PA turnaround performance directly influences MA quality scores

Ready to Transform Prior Authorization?

Let's model your PA volume, current auto-approval rate, and CMS-0057-F compliance gap, then show you exactly where PriorAuth1™ delivers value.