Prior Authorization
Solution

Improve workflow predictability and unify
submission channels.

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Prior Authorization is part of Cotiviti's Interoperability solution suite.

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Beyond connectivity, an effective prior authorization solution is interoperable across a range of submission formats, seamlessly integrates with legacy systems, and provides automation tools intended to reduce costly rework.

93%

of physicians reported that prior authorization delays patient care.

 2025 AMA Survey

Unify every prior authorization workflow

Supported by a robust library of pre-built enterprise connectors, Cotiviti’s Prior Authorization solution is available standalone or as part of FHIR Gateway and supports CMS-0057-F requirements while bridging legacy submission channels and modern interoperability standards within a single workflow.

Prior Authorization solution benefits

  • Improve workflow predictability and support consistent communication between providers and payers with a single handshake (FHIR-based provider access API and prior auth API)
  • Consistent data standards by unifying all incoming FHIR, EDI, fax and portals prior authorization submissions into a single channel
  • Automate routing and workflow rules for PA requests based on user-defined business logic (e.g., procedures and diagnosis codes); ensure outbound file formats match endpoint type
  • Orchestrate across core decision-making systems using Cotiviti's out-of-the-box connections to medical policy, utilization management ad delegated review systems
  • Accelerate PA workflows, reduce burden and meet compliance SLAs with AI-enabled intake to convert manual fax submissions into standard FHIR format
  • Increase visibility across the prior authorization lifecycle by tracing individual transactions through delivery verification in the Transaction Management interface
  • Support CMS 57-F and future requirements by enabling FHIR-based APIs for CRD (which services require PA), DTR (documentation requirements) and PAS (requests and responses between payer and provider)

Fax-to-FHIR

Simplify provider workflows and deliver cleaner payer data.

Cotiviti’s Fax-to-FHIR extension allows you to validate prior authorization requests before they reach payer systems. It routes requests to the right systems using intelligent routing and business rules you define and supports orchestration across the entire ecosystem with standard third-party integrations while delivering 98% AI model accuracy* in fax submission conversions.

Flexible submission

Create a new, digital prior authorization or upload an existing PA form for FHIR workflow conversion.

First-pass validation

Catch missing or incorrect information before rework or denial.

Standardized data

Convert reviewed and approved data into FHIR bundles and reduce manual interpretation.

Faster turnaround

Unifying previously disconnected workflows and routing requests to the right reviewer, system, or partner using payer-defined rules.

 

*Based on internal projections. Results may vary depending on factors including but not limited to prior authorization volume and request types.

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