MEDICAL PRIOR AUTHORIZATION MADE SEAMLESS WITH PAHub

Improve Clinical Efficiency & Compliance with Agadia’s fully configurable web-based solution, PAHub.

Medical Prior Authorizations
medical prior authorizations

The Industry Challenge

Evolving Needs in a Post-Pandemic World

The healthcare industry is facing increased cost pressures while trying to balance compliance, efficiency, and patient care. Prior authorization processes often create unnecessary burdens for providers and patients due to outdated workflows and siloed systems.

Meanwhile, advancements in automation, artificial intelligence, and regulatory standards like CMS 0057-F are paving the way for next-generation solutions. It’s time to assess your current prior authorization approach to meet today’s demands and prepare for tomorrow’s challenges.

Agadia: Proven Expertise Since 2007

A Trusted Partner in Utilization Management

A Market Leader

Serving nearly 100 million covered lives through customers across all 50 states and Puerto Rico.  Over 1.6 million medical prior authorizations processed annually.

HITRUST Certified Solutions

Agadia’s solutions are proudly HITRUST-certified, representing the highest standard in safeguarding patient data and ensuring compliance with rigorous security, privacy, and risk management requirements.

Broad Scope

Supporting all lines of business—commercial, Medicare, and Medicaid—and channels, including ePA, phone, fax, web, and EMR integrations.

Privately Held & Customer Focused

Agadia proudly offers flexibility, transparency, and tailored solutions, free from the constraints of public or private equity backing.

Why Choose Agadia for your
Medical Prior Authorization Needs

Comprehensive and Configurable

Full control to configure clinical, operational, and compliance rules.

Seamlessly supports all CPT and HCPCS codes, ensuring compatibility across all categories, including radiology, musculoskeletal, DME, lab, surgery, and behavioral health.

Tailored workflows to meet delegated and non-delegated requirements.

Built for Compliance

Proven track record of supporting CMS audits for over 13 years.

Ready for CMS 0057-F compliance, with integrated solutions for InterQual, CMS, and custom criteria.

Cutting Edge Technology

Real-time integration with claims systems for efficient automation and decision-making.

Advanced AI and NLP capabilities to reduce manual intervention and improve accuracy.

8-9 enhancement releases annually to ensure your solution stays ahead of the curve.

Automation at Scale

Auto-decisioning and ePA capabilities for faster approvals.

Customizable letter generation and communication management tools to reduce administrative burden.

Medical record scraping and EMR integration underway for next-gen functionality.

Efficiency Across Both Benefits

A Seamless Single Platorm for Med and Rx Prior Authorizations

Agadia’s PAHub provides a seamless solution for both Medical and Pharmacy Benefit prior authorizations. This unified platform eliminates the complexities of managing separate systems, allowing payers to streamline procurement and operations.

medical benefit prior authorization

Ready for the Future

Navigating the CMS Interoperability & Prior Authorization Final Rule

CMS Final Rule Provisions & PAHub’s Key
Contributions to Address These Requirements

Facilitated in the Payer’s Upstream EcoSystem

Facilitated in PAHub
Medical Prior Authorizations

Patient Access API:
The rule mandates the implementation of an HL7® FHIR® Patient Access API, including information about prior authorizations, by January 1, 2027. To ensure transparency and patient understanding, impacted payers are required to report annual metrics on Patient Access API usage starting January 1, 2026.

 

Provider Access API:
To support care coordination and value-based payment models, impacted payers must implement and maintain a Provider Access API by January 1, 2027. This API facilitates the exchange of patient data, including individual claims, encounter data, and specified prior authorization information.

Payer-to-Payer API:
To enhance care continuity during payer transitions, impacted payers are obligated to implement and maintain a Payer-to-Payer API by January 1, 2027. This API enables the sharing of claims and encounter data, fostering seamless access to relevant patient information.

 

Prior Authorization API:
Impacted payers are required to establish and maintain a Prior Authorization API, ensuring standardized communication on covered items and services. The API must convey approval, denial, or requests for more information regarding prior authorization, with implementation starting January 1, 2027.

 

Prior Authorization Decision Timeframes
Impacted payers (excluding QHP issuers on the FFEs) are required to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests.

 

Provider Notice, Including Denial Reason:
Beginning in 2026, impacted payers must specify the reason for PA denials, communicated through various methods like portal, fax, email, mail, or phone. This aims to enhance communication, transparency, and provider resubmission capabilities, excluding prior authorization decisions for drugs, with existing notice requirements for certain payers remaining unchanged.

 

Prior Authorization Metrics:
Impacted payers are required to publicly report certain PA metrics annually by posting them on their website. These operational or process-related policies are being finalized with a compliance date starting January 1, 2026, and the initial set of metrics must be reported by March 31, 2026.

 

Required Standards and Recommended Implementation Guides (IGs) for APIs:

Ready to Transform Your Prior Authorization Approach?

Schedule a Demo

Join the health plans and PBMs leveraging PAHub to drive operational efficiencies, ensure compliance, and enhance provider and patient satisfaction.

Phone

877-575-2533

Email

contact@agadia.com

Location

9 Campus Drive, Parsippany NJ 07054

Schedule Live Demo