Leading health insurers have committed to modernizing the prior authorization process by 2027, with Availity’s Intelligent Utilization Management solution already demonstrating capabilities for real-time decisioning and streamlined workflows.
The pledge by prominent health insurers outlines a commitment to real-time decisions, standardized electronic workflows, and enhanced transparency in the authorization process. This industry-wide initiative aims to transform utilization review into a more efficient and accessible component of healthcare delivery.
Availity, which operates the nation’s largest dual-sided, real-time healthcare network connecting over 3.4 million providers and more than 95% of health plans, highlights its Intelligent Utilization Management solution as a tool capable of delivering authorization results in 90 seconds or less. Russ Thomas, CEO of Availity, stated, “Our providers tell us that authorizations are the most frustrating part of their health plan relationship; not that they aren’t necessary, but that the utilization review process is unduly burdensome and complex. Technology empowers us to reimagine authorization workflows more creatively, so that utilization review can serve the intended purpose in a way that makes care accessible, appropriate and available when you need it.”
The health plans’ agreement includes several key reforms: standardizing electronic submissions, providing real-time answers for at least 80 percent of complete requests, offering clearer explanations for denials, and ensuring a 90-day continuation of previously approved care when members switch plans. Availity’s solution aligns with these objectives, having processed over 1 million authorization requests in its first year of implementation. Of these, 80 percent were approved in under 90 seconds from submission, with a majority returned within 20 seconds.
The Availity Intelligent Utilization Management solution is currently in use with plans covering more than 17 million lives. Additionally, five national and regional health plans, collectively representing over 45 million members, are contracted for deployment in 2025. This indicates a broader industry movement toward investing in technology that can surpass existing regulatory mandates and improve the authorization experience for providers and patients.
Intelligent Utilization Management is a modular, AI-powered solution designed to streamline prior authorization by reducing administrative burden, enhancing transparency, and accelerating access to medically necessary care. Built with FHIR®-based APIs, the system is designed to assist health plans in meeting CMS interoperability mandates. It integrates directly into provider workflows to enable real-time or near real-time decisioning. Unlike traditional solutions that often rely on manual review or predictive models, Availity’s system leverages auditable AI and clinical data extraction to evaluate medical necessity at the point of care, aiming for faster, more transparent decisions and fewer delays. Determinations are provided in seconds, facilitating more efficient prior authorization.
Availity’s proprietary clinical engine delivers transparent, criteria-based recommendations grounded in the health plan’s codified medical policy, which is a requirement for Medicare Advantage plans navigating federal guidelines and regional variations. The solution was developed to support the CMS final rule and features a modular, EMR-integrated workflow that simplifies submissions for providers. It also supports delegated vendor integration, customizable automation rules, and an ecosystem of partners, offering health plans flexibility to scale their Utilization Management programs while enhancing provider satisfaction and operational efficiency.
Availity’s architecture facilitates direct, bi-directional data exchange between payers and providers, eliminating intermediaries and reducing latency. This enables synchronized workflows, allowing payers to configure medical policies and decision logic at scale, and providers to submit and resolve authorizations directly within their native EHR environments. For patients, this aims to result in faster access to care and fewer treatment delays. Matt Cunningham, Availity’s Executive Vice President of Product, stated, “Availity is providing a foundation for lasting change—combining cutting-edge technology with deep domain expertise and a collaborative, service-first approach. We give payers a path to go further: reduce unnecessary authorizations altogether, automate the ones that remain, and rebuild trust through transparency and traceability every step of the way. The health plans’ pledge and the CMS final rule align perfectly with that vision.”
Availity, based in Jacksonville, Florida, focuses on enabling the exchange of clinical, administrative, and financial information to support healthcare innovation. The company’s network connects over 95% of payers, more than 3.4 million providers, and 1,700 trading partners.
