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Fix Prior Authorizations: Faster, Smarter, and CMS-Ready

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Prior authorizations were designed to ensure appropriate care, but manual processes and fragmented systems have turned them into one of the biggest sources of care delays, frustration, and cost in healthcare.

Availity changes that.

Availity AuthAI™ combines transparent, responsible AI with the nation’s most powerful network of health plans, providers, and HITs to reduce administrative waste without compromising care.

We deliver what health plans need – transparency and control; what providers want – speed and consistency; and help support what patients deserve – timely, evidence-based care.

Availity’s Intelligent Utilization Management is Built for Better Prior Authorizations.

Built for Better Decision Making

Availity AuthAI delivers real-time, policy-aligned recommendations, not predictions based on regression models. Every recommendation is traceable, auditable, and grounded in a health plan’s medical criteria.

Built for Better Experience

Availity AuthAI gives providers a clear, fast, more consistent experience allowing more time with patients, and less time on calls.

Built for Better Interoperability

Availity’s FHIR®-native platform connects health plans, providers, and HIT systems through secure APIs—ready for CMS 0057 compliance and beyond.

Built for Better Scale

Modular, API-driven infrastructure meets you where you are and grows with your strategy; no rip-and-replace required.

Learn how black box AI puts health plans at risk.

Proven Results

How Availity AuthAI™ Improves Utilization Management

76%

of prior authorization requests receive near real-time approval recommendation

97%

of requests are submitted with clinical data or informed questions answered

100%

of providers notified of unnecessary prior authorization requests

95%

reduction in appeals and grievances

“With Availity, we are now receiving 98% of our prior auth requests electronically.”

VP Utilization Management

Transparent, Policy-Based AI That Keeps Payers in Control 

Availity AuthAI uses clinical data and a health plan’s existing medical policy—not historical guesses or predictive models—to make real-time determinations. It’s not a black box.  There is visibility in how every recommendation is made, the ability to override any recommendation, and the health plan remains in control. For complex cases, Availity AuthAI surfaces the most relevant data in an easy-to-read format, helping clinicians make confident decisions—faster.

Real-Time Prior Authorization Decisions That Accelerate Patient Care

Availity AuthAI delivers authorization recommendations to providers quickly so patients can receive the care they need, when they need it. Because the system requires most prior auth submissions to include necessary clinical information, Availity AuthAI can render a recommendation in near real time—less than 90 seconds on average. 

Nationwide authorization connectivity that helps meet the CMS mandate

Availity’s connected network of payers nationwide and more than 3.4 million providers, combined with a robust API portfolio that features the FHIR APIs included in the CMS-0057 Final Rule, build the foundation for a better, more connected future without vendor sprawl.  Just smart, scalable tools that work.

Intelligent Utilization Management Frequently Asked Questions

Does Availity AuthAI use Generative AI (GenAI)?

No. Availity AuthAI is built using an Analytical AI model. Analytical AI analyzes and interprets complex data sets, uncovers meaningful insights, and makes data-driven predictions and recommendations. It uses explicit rules and logic for greater transparency and proficiently analyzes vast amounts of structured and unstructured data, and it effectively detects hidden trends. It is much better suited for healthcare use cases, such as Utilization Management, than GenAI.

In comparison, GenAI generates new content such as images, text, or music by drawing from learned patterns in existing data. Because of its risk of hallucinations, as well as biases and fairness issues, GenAI is not optimal for use cases that require strict adherence to precision.

Is Availity’s utilization management solution compliant with CMS-0057?

Yes. Availity’s intelligent utilization management solution meets CMS-0057 Final Rule requirements and is already in use by many major health plans. Starting January 1, 2027, health plans must use three FHIR® APIs to accelerate prior authorization approvals for patient care:

  • Coverage Requirements Discovery (CRD) – tells providers if prior authorization is needed.
  • Documentation Templates and Rules (DTR) – automates gathering the right clinical data.
  • Prior Authorization Support (PAS) – enables electronic submission and response.

See how Availity automated end-to-end prior authorizations using FHIR APIs.

What safeguards are in place to prevent bias or inappropriate denials when using AI?

Availity AuthAI does not auto‑deny, deny or approve prior authorizations. AvailityAuthAI is a recommendation engine, not a decisioning engine. The engine uses Analytical AI to assess the patient’s clinical data and make recommendations based on their medical policy. The system does not use historical data, regression models, or any other black-box methodology.  Availity’s AI Governance aligns to CMS guidance that coverage determinations must consider the individual patient’s circumstances, including controls to mitigate bias and support nondiscrimination requirements.

Download Availity’s Responsible Artificial Intelligence Principles

How does Availity AuthAI ensure transparency, auditability, and clinical integrity in its recommendations?

Availity AuthAI “shows its work” by aligning the patient’s clinical data to codified policy logic using Clinical Quality Language (CQL). CQL is an HL7® standard that expresses clinical logic in a way that humans can read, and machines can execute. All recommendations are traceable and align with the appropriate policy; pended cases requiring human review are surfaced with relevant evidence visually organized for easy access.

What makes Availity’s approach to AI in utilization management different from other solutions in the market?
  1. The Availity Platform: Nationwide connectivity improves provider experience with a single digital front door to more than 170 health plans. Payers control technology spend by relying on Availity’s secure infrastructure and gain access to more than 3.4 million providers
  2. Clinical Integrity: Analytical AI grounded in codified medical policy uses each unique patient’s data to make recommendations.
  3. Durable Recommendations: Consistent case recommendations rooted in traceable data help reduce grievances and minimize overturned appeals.
How does the solution integrate with UM platforms, EHR systems, and delegated vendors?

Availity’s Intelligent Utilization Management solution is platform‑agnostic, integrating via FHIR® API to UM systems and any EHR. Configuration at implementation enables requests to route to or from delegated vendors supporting insourced, outsourced, or hybrid UM operating models.

Does Availity AuthAI address the end-to-end prior authorization process, or is it a point solution?

Availity AuthAI is one component of Availity’s Intelligent Utilization Management solution that delivers end-to-end automation of the prior authorization workflow.

  • Intake & Submission: Providers submit requests directly from their EMR workflow, or in Availity’s multi-payer portal.
  • Attestation: FHIR® APIs (CRD, DTR, PAS) support “is auth required” queries responding with “no auth required” or the necessary attestation protocol to gather the right clinical data from the provider’s EHR at the start.
  • UM Decision support: Availity AuthAI applies codified medical policy using transparent, auditable logic to recommend approvals in near real time for routine cases.
  • UM Exception handling: For complex cases, Availity AuthAI organizes clinical evidence for UM clinicians, simplifying and streamlining manual reviews without sacrificing clinical integrity.
  • UM Feedback loop: Availity AuthAI captures outcomes and updates medical policy logic, improving recommendation accuracy over time.
  • Determination: Auth recommendations are returned via FHIR® API to provider via EMR workflow, or in Availity’s multi-payer portal.