Prior Authorization Overview
Manual prior authorization (PA) is a roadblock—ditching patient access, inflating costs, and draining your clinical teams. Genzeon’s prior authorization automation programs go beyond digitization. We harness specialized AI decision agents powered by deep clinical guidelines to eliminate delays, reduce burnouts, and improve affordability—delivering smarter, faster, and more human-centered care.
Real-time flags for missing evidence during documentation—submission-ready forms every time.
Pre-checks ensure completeness—resulting in fewer denials, reduced back-and-forth, and faster approvals.
Agentic guidance surfaces matched guidelines and triages effectively, giving nurses smarter decisions in a snap.
Video | Webinar
In this on-demand webinar, hear from a panel of seasoned healthcare and automation experts from Genzeon and UiPath as they unpack the critical challenges and emerging opportunities in prior auth transformation.
Regulations and Compliance
CMS mandates begin in January 2026.
CMS has finalized rules (e.g., CMS-0057-F) requiring payers to streamline prior authorization processes.
Key changes include tighter response times, transparency requirements, and mandated adoption of standardized APIs for electronic submission and status tracking. See the matching graphic for more information on these deadlines.
Healthcare Platform
HIP One uses advanced AI and GenAI to boost clinical and business team productivity by 30–50%. Its built-in security and compliance ensure innovation meets industry standards. For prior authorization needs, Medical Review helps clinicians deal quickly with high complexity claims in a fraction of the time.
Our Insights
CMS has finalized rules (e.g., CMS-0057-F) requiring payers to streamline prior authorization processes. Key changes include tighter response times, transparency requirements, and mandated adoption of standardized APIs for electronic submission and status tracking.
The major deadlines start in January 2026–2027, with different dates for implementing APIs, interoperability standards, and turnaround time expectations. Payers should be actively preparing now to meet compliance.
Medicare Advantage organizations, Medicaid and CHIP managed care plans, state Medicaid agencies, and Qualified Health Plan issuers on the federally facilitated exchanges. Many commercial plans have voluntarily agreed to meet the same deadlines, but are not covered by the CMS rules.
Payers must provide clear, specific denial reasons, publish metrics (such as approval/denial rates and turnaround times), and make prior authorization information publicly accessible.
