Unified Medical and Pharmacy Utilization Management on a Single, CMS-Ready Platform
Helping health plans automate prior authorization, reduce turnaround times, and stay compliant without the complexity of legacy systems.
Understanding Medical UM
What is Utilization Management?
Utilization management (UM) is the process health plans use to ensure that medical services are appropriate, cost-effective, and aligned with clinical guidelines. It includes prior authorization, concurrent review, and retrospective review to manage care quality and costs.
Modern utilization management software enables:
- Automated prior authorization workflows
- Clinical criteria-based decisioning
- Real-time communication with providers
- Regulatory compliance and audit readiness
Key Differentiators Between
Medical & Pharmacy Prior Authorization
With Agadia’s PAHub solution, Health Plan and PBMs can benefit from:
- One workflow across both benefits
- Shared clinical criteria and rules
- Consistent member and provider experience
Medical Benefit PA
Automating Clinical Decisioning
with Evidence-Based Criteria
Manual clinical review slows down decisions and increases administrative burden.
Agadia automates decisioning using proven clinical intelligence and automation.
Seamless Integration with
EMRs and Provider Workflows
Disconnected systems create friction for providers and delays for members.
Agadia connects your systems, workflows, and people so information flows seamlessly and decisions happen faster.
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
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.
