The 5 Operational Shifts UM Leaders Should Make in 2026 

For Utilization Management (UM) leaders, 2026 is not a normal operating year. It’s the countdown to January 1, 2027, when the long-standing industry expectations will be enforceable by the CMS Interoperability and Prior Authorization Final Rule (CMS-0057). Impacted payers need to report metrics publicly, make accurate determinations, provide clear denial rationale, and deliver interoperability between payers and providers.  

Health plans aren’t just racing to stand up the required FHIR® APIs ahead of the compliance deadlines, they’re redesigning UM operating models to bring more control in‑house, increase transparency for providers and members, and adopt more agile processes.

This blog highlights five operational shifts UM leaders should prioritize in 2026 to not only help meet mandatory compliance, but also reduce administrative burden, improve provider satisfaction, and take back control of care management and member engagement. 

Shift 1: Bring Select PA Cases Back in House for More Consistent and Timely Decisions

For years, delegated UM models promised efficiency for prior authorization (PA), but they often left health plans with limited visibility and no control over prior authorization decisioning; two things CMS-0057-F makes non-negotiable. Meeting the compliance deadline means more than simply hitting turnaround times and deploying API endpoints. It means health plans are responsible for the decisions that influence member cost, care quality, and overall experience.

Bringing select PA workflows back in-house gives health plans the control to execute faster decisions with auditable, transparent determinations. Automation and AI enable this transition by making it possible to quickly scale routine approvals, auto-populate attestation questionnaires, and intelligently route complex cases for human review, while reducing manual work. Check out the latest blog in our UM transformation series for more insights on determining which PA cases to insource and which to delegate.

Shift 2:  Evaluate Authorization Intake Strategy for More Accurate Submissions 

Accurate prior authorization (PA) determinations start with accurate submissions. Multiple intake channels (portals, fax, EMR, etc.) lead to unnecessary complexity in PA workflows. UM leaders need strategies to help ensure every submission includes the necessary clinical information to ensure clinical integrity and accelerate turnaround time .

To address this challenge, health plans need a single digital front door that consolidates intake channels into a single workflow that then converts submissions to the appropriate format and routes each submission to the correct endpoint. Whether handled by an internal review team or a vendor, this approach streamlines PA workflows and reduces the risk of mistakes and backlogs that occur when PA requests are managed in silos.

It’s also worth considering how AI-guided questionnaires can support clinical integrity. By leveraging the patient’s clinical documentation and claims data to auto-fill attestation fields, and prompting relevant missing information, health plans receive robust clinical information while reducing provider abrasion.

The result? Accurate submissions that support durable decisions and a smooth member experience.

Shift 3: Go Beyond Digitization for Automation and Audit Readiness 

Many organizations have pursued automation by digitizing medical policies to meet the CMS-0057-F requirements. But in practice, digitization simply translates medical policy(ies) text into a digital format and repackages it as clinical questionnaires. The result is often long, rigid forms that slows intake and frustrates physicians.

That’s why in 2026, leading UM teams are moving beyond digitization toward medical policy codification, not as a technology upgrade, but as a strategic capability.

Instead of a series of disconnected digitized questionnaires, codification creates a single integrated decision tree — sequencing questions in a natural, clinical order while maintaining alignment with all relevant policies. This underlying model helps enable innovative technology, such as analytical AI, which can be used to organize clinical evidence for UM clinicians to simplify and streamline manual reviews without sacrificing clinical integrity.

For UM teams planning for 2027 CMS-0057-F compliance, the question is no longer whether to digitize medical policies. The real question is whether your policies are structured to support intelligent automation, clinical trust, and regulatory resilience at scale.

Shift 4: Leverage Responsible AI for Speed, Consistency, and Clinical Control

Automation is no longer optional in PA workflows, but how you automate matters as much as what you automate. The goal isn’t to replace clinical judgment. It’s to reduce manual work while protecting the clinical integrity that providers and regulators expect. Ethical, responsible AI and human-in-the-loop oversight are what make this approach work.

Automated decisions must be explainable, auditable, and tied directly to published medical policy. When a request falls outside policy guidelines, it should automatically route to a human reviewer. This helps build provider trust, supports compliance under CMS-0057, and avoids “black box” decisioning.

When done right, responsible AI strengthens, not replaces, clinician oversight, helping UM teams move faster while building trust with providers and members.

Shift 5: Operationalize RealTime UM Metrics for Transparency, Trust, and Continuous Improvement

Standing up mandated FHIR APIs and automating determinations shouldn’t be the finish line. With CMS-0057 raising expectations, UM leaders need to move beyond after-the-fact reporting and make visibility into real-time performance part of daily operations.

This shift means embedding measurements directly into UM workflows to enable executive-ready dashboards that track turnaround times by service categories and approval/denial rates with clear reason codes, exception volumes, and indicators of provider abrasion. When paired with explainable, policy-driven automation, these metrics become audit-ready by design. Every decision, trend, and improvement clearly tied back to clinical criteria.

Getting there doesn’t require overengineering. PA design intake and decision workflows create real-time visibility, clear KPI ownership, and the ability to set thresholds that automatically flag exceptions. UM teams review trends regularly to refine criteria, routing, and staffing. This is how UM shifts from meeting compliance requirements to building confidence, that is supported by real-time insights, with providers, regulators, and health plan leadership.

How Availity Can Help

Transforming Utilization Management in 2026 isn’t only about adopting new technology, it’s about operationalizing smarter, faster, and more transparent PA workflows. Availity’s Intelligent Utilization Management solution is designed to help health plans implement these five operational shifts, from codifying medical policies for AI-driven automation to embedding real-time metrics that drive confidence with providers and regulators.

Whether you’re bringing prior authorizations back in-house, scaling automation responsibly, or creating a performance-driven culture, Availity provides the technology, insights, and guidance to help make the shift smoother and more effective.

If you’re ready to move from concept to execution, use the button below to request a demo and see how Availity can help transform your prior authorization workflows.

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