of appealed standard-request denials overturned by the large insurers KFF analyzed, across three market segments, 2025of appealed denials were overturned at the median plan in the first year of public CMS-0057-F data.
AuthDenied via Forvis Mazars, Aug 2026
See what’s holding every prior authorization request
Connect intake, case preparation, specialty routing, clinical review, escalation and appeal, and see the missing information, owner and next action on every open request.
Built for CMS-0057-F decision windows and annual public reporting.
Built for CMS-0057-F decision windows and annual public reporting.
A prior authorization request can arrive in seconds and still wait days for a decision.
When the work spans intake platforms, utilization management systems and delegated vendors, a status of “pending” says little about what is holding the request. Health plan leaders need a view of each request at the task level: which task is open, who owns it and what it needs.
APPEAL OUTCOMES
43% to 67%
DECISION WINDOWS
72 hrs / 7 days
maximum decision windows for expedited and standard requests since Jan 1, 2026. Applies to specified impacted payers; excludes QHP issuers on federally facilitated exchanges and drug PA.for expedited and standard decisions in Medicare Advantage, Medicaid and CHIP since January 2026. QHP issuers on federal exchanges and drug prior auth are excluded.
CMS-0057-F
CMS-0057-F
Give AI one job, the information to do it and a person to call when it cannot.
Within an agreed workflow, AI can:
- Identify missing information at receipt
- Assemble the reviewer’s case file
- Recommend specialty routing and flag likely misroutes
- Flag work approaching a deadline
Teams keep responsibility for exceptions, and qualified clinicians keep medical-necessity determinations.
THE OPERATING MODEL
One connected view of every task
Each stage passes the case to the next with its evidence attached. Automation handles preparation, TeleMedik licensed clinicians handle review, and the record links the two at every step.
Every request captured, classified and time-stamped at first touch
Requests captured across fax, mail, phone, portal and electronic channels
Case type and urgency identified against the 72-hour expedited or 7-day standard window
Exceptions flagged and routed to a named owner
Audit trail starts with the request, its source and its timestamp
Case type and urgency identified against the 72-hour expedited or 7-day standard window
Exceptions flagged and routed to a named owner
Audit trail starts with the request, its source and its timestamp
The reviewer’s packet, assembled and checked before review
Relevant records consolidated into a standard packet for each request type
Missing documentation flagged and requested before the case reaches a reviewer
Preparation status visible on every open case
Missing documentation flagged and requested before the case reaches a reviewer
Preparation status visible on every open case
Clinical judgment stays with licensed clinicians
Clinical review by TeleMedik licensed clinicians
Relevant information and applicable criteria presented together
Reviewer time goes to clinical judgment
Review responsibilities and qualifications defined with each plan
Relevant information and applicable criteria presented together
Reviewer time goes to clinical judgment
Review responsibilities and qualifications defined with each plan
Every potential denial gets physician review and a documented reason.
Potential denials escalated to physician review
A specific reason recorded on every denial
Each decision linked to its reviewer and supporting evidence
Notices issued after the required checks and approvals
A specific reason recorded on every denial
Each decision linked to its reviewer and supporting evidence
Notices issued after the required checks and approvals
Appeals start from the original decision record.
The original request, evidence, criteria and rationale retrievable on appeal
Original determination and appeal outcome kept in one record
Re-review handled under the plan’s independence requirements
Original determination and appeal outcome kept in one record
Re-review handled under the plan’s independence requirements
ACROSS EVERY STAGE:
ANALYTICS AND REPORTING
See your numbers before they are published.
Decision-window performance tracked for expedited and standard requests
Denial and overturn patterns tracked by service category
Volume and capacity trends surfaced early
Documentation structured to support CMS-0057-F reporting
WHY FIRSTSOURCE
Built for how prior auth actually works
Works across your systems
Prior auth spans radiology, oncology, behavioral health, lab and post-acute care, often across several platforms and delegated vendors. The model is designed to work with the core administration and UM platforms you already run.
Clinical review at the decision point
TeleMedik's licensed clinical reviewers sit inside the workflow where decisions are made, with escalation paths agreed up front.
Model-agnostic automation
As AI models change, you keep control of your data, your decision logic and your audit trail.
Certified security
HITRUST, SOC 2 Type 2 and ISO 27001. Operations built to HIPAA requirements.
BUILT FOR
The people accountable for getting this right
Different roles carry different parts of this problem.
- VP, Utilization Management: reviewer capacity without compromising review quality.
- Compliance / Regulatory Affairs: a documented decision trail aligned to CMS-0057-F requirements.
- Chief Medical Officer: clinical review that physicians can see in the record.
- VP, Claims: clearer decision records when prior auth outcomes reach claims.
- VP, Appeals & Grievances: appeals that start from the original decision record.
PROOF
What this looks like in practice
A regional Medicare and Medicaid plan serving 1.2 million members implemented Firstsource's Sympraxis® Health Plan Communication Hub to automate intake: information extraction, member and provider ID validation, case creation and acknowledgment letters. Combined with global delivery, the engagement produced these results.
OPERATING COST: 45% reduction in PA intake operating cost.
Regional Medicare and Medicaid plan, 1.2 million members. Scope: PA intake through the Health Plan Communication Hub.
URGENT-APPEAL PROCESSING: 66% less processing time, 12 hours to 4.
National, top-tier U.S. health plan. Scope: from identification as urgent, AI/ML-supported triage.
MAILROOM TURNAROUND: 48 hours to 8; data-capture accuracy from 95% to 99%.
National health plan, 50 appeal categories. Scope: mailroom processing and data capture.
These results measure administrative and triage work. They do not measure clinical decision accuracy or end-to-end PA turnaround.
BEYOND PRIOR AUTH
Prior auth is the front door to clinical growth
Authorization activity is one of the earliest signals of where members are heading. Firstsource's clinical capabilities, strengthened by the TeleMedik acquisition, also span care management, disease management and population health. Prior auth can be the first step in a broader clinical operating model.
FAQ
Does AI make coverage decisions?
No. Automation supports intake, classification, evidence assembly and documentation checks. Clinical review stays with licensed clinicians, and potential denials go to physician review. Review responsibilities, including how any rules-based approvals work, are defined with each plan.
Which CMS-0057-F requirements apply now?
Since 2026, Medicare Advantage, Medicaid and CHIP plans must decide expedited requests within 72 hours and standard requests within 7 calendar days. Impacted payers, including QHP issuers on the federal exchanges, must give a specific reason for each denial and publish prior auth metrics annually, starting March 31, 2026. QHP issuers on the exchanges are excluded from the decision windows. Most API requirements start January 1, 2027. Exact dates vary by payer type, and drug prior authorization is excluded.
Do we need to replace our UM platform?
No. The model is designed to work with the core administration and UM platforms a plan already runs. Integration scope is confirmed during implementation.
Where do we start?
With your published metrics. They show where questions are worth asking. A short review of the underlying workflow then shows where to begin.