AI-driven member service, claims and utilization management.
Member service, prior authorization, claims, appeals and provider data — automated end-to-end for health plans, instrumented for STARs/HEDIS/CAHPS and CMS-0057-F prior-auth API mandates.
Ranges reflect outcomes observed across Pronix payer engagements; results vary by line of business (Commercial, Medicare Advantage, Medicaid), core admin system and starting service baseline.
Payer operations are the single most under-automated area in healthcare — and the most regulated.
Members struggle to reach anyone. Providers wait days for authorizations. Claims processing depends on manual review at every exception. CMS's 2024 Interoperability and Prior Authorization Final Rule (CMS-0057-F) resets the clock on API-based prior auth and provider access — with 2026/2027 deadlines already on payer roadmaps.
- Member service under pressureSTARs, HEDIS and CAHPS ratings all reflect service quality — and legacy contact centers are the bottleneck.
- Prior auth is the top provider abrasion pointCMS-0057-F requires a Prior Authorization API, decision timelines and public reporting. Days-long turnarounds cost members care, burn provider relationships and now fail compliance.
- Provider data driftDirectory accuracy is a compliance risk and a service failure — automation is finally viable.
Payer-tailored AI and CX capabilities.
Claims-status IVA with member auth, knowledge-grounded responses on benefits, EOB and denial reasons — up to 45% containment.
End-to-end automation with clinical review and human-in-the-loop for edge cases, aligned to CMS-0057-F API and timeline requirements.
IDP extracts key fields from op notes, EOBs and itemized bills, aligns to the claim and flags missing data before adjudication.
Azure OpenAI agent assembles case timeline, cites policy and drafts decision letter for reviewer — 50% cycle-time reduction on standard appeals.
Ongoing directory validation, roster automation and network adequacy checks with governed AI.
Central eval harness, model registry, red-teaming and PHI-aware guardrails across payer AI use cases.
A six-step model, from assessment to managed operations.
Every engagement follows the same rhythm — so business, IT and delivery stay aligned from opportunity to outcome.
Member journey and ops baseline.
AI architecture, PHI model, evals.
One line of business, measurable KPIs.
Core systems integration and rollout.
Lines of business, regions, languages.
Managed operations with clinical oversight.
Use cases already in production with enterprise clients.
IVA fronts the claims platform with knowledge-grounded responses and secure auth — 45% containment, 25% AHT reduction on transferred calls.
Enlighten + custom topic models surface Stars/CAHPS drivers and coaching moments — measurable driver lift within two quarters.
Agent assembles case timeline, cites policy and drafts decision letter — reviewers edit and approve rather than draft from scratch.
IDP extracts key fields, aligns to the claim and flags missing data — cycle-time reduction on attachment-blocked claims.
Continuous directory validation, roster automation and network adequacy — compliance risk reduced, provider abrasion down.
Central eval harness, model registry and red-teaming across payer AI — defensible audit trail per model version.
CMS-0057-F Prior Authorization Readiness POV
What the 2024 CMS Interoperability and Prior Authorization Final Rule actually requires — Prior Authorization API, Provider Access API, decision-timeline and reporting mandates — and a working reference for meeting the 2026/2027 deadlines with agentic prior-auth and IDP.
Pronix service lines aligned to health payers outcomes.
Strategy, implementation and operating support are combined around the service motions most relevant to this industry.
Grounded on your data. Governed on day one.
Every platform we implement is only as good as the retrieval, connectors and controls behind it. These are the horizontal solutions we ship with every engagement.
Questions buyers ask us first.
- How does this align with CMS-0057-F?
- Our prior-auth automation is designed to meet the Prior Authorization API, Provider Access API, decision-timeline and public reporting requirements of the CMS Interoperability and Prior Authorization Final Rule (2024), with agentic workflows for clinical review and human-in-the-loop where regulation requires it.
- Do you integrate with core payer platforms?
- Yes — HealthEdge, Facets, QNXT and custom cores via standard APIs and message-bus patterns.
- Can you improve our STARs / CAHPS?
- Yes — service redesign, care-gap outreach, member communication and conversation analytics (NICE Enlighten) surface Stars/CAHPS drivers with measurable lift within two quarters.
Book a working session with our health payers team.
30 minutes. Your architecture, your data, your KPIs. You leave with a concrete pilot outline and a business case worth defending.