Prior Authorization
Solution

Improve workflow predictability, unify legacy and
modern submission channels

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

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Prior authorization (PA) is one of the most difficult processes to navigate in healthcare. Disparate submission methods, disconnected systems, and complex decision workflows all contribute to inefficiencies. 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

Cotiviti's unified, end-to-end prior authorization solution bridges legacy submission channels and modern interoperability standards within a single workflow.

While CMS-0057-F will accelerate adoption of FHIR-based APIs (CRD, DTR and PAS), the industry will continue to rely on a hybrid operating model for years to come, leaving workflow variation as a constant drag on operations and limiting the full value of interoperability investments.

Cotiviti solves this challenge by supporting regulatory requirements while applying AI to convert unstructured fax submissions into standardized FHIR transactions for greater coordination, visibility and predictability across the prior authorization lifecycle.

Prior authorization is not a connectivity problem – it's an orchestration problem.

Removing wasted effort from the prior authorization process requires surfacing the right information in the right format at the right time for stakeholders and systems to act decisively. Supported by a robust library of pre-built enterprise connectors and available standalone or as part of FHIR Gateway, Cotiviti's prior authorization solution acts as the configurable interoperability layer that orchestrates these interactions.

Source: 2025 AMA Survey

Prior Authorization solution benefits

  • Improve workflow predictability and ensure consistent communication between providers and payers with a single handshake (FHIR-based provider access API and prior auth API)
  • Ensure consistent data standards by unifying all incoming FHIR, EDI, fax and portals prior authorization submissions into a single channel
  • Automate routing and decision rules for PA requests based on user-defined business logic (e.g., procedures and diagnosis codes); ensure outbound file formats match endpoint type
  • Easily integrate with core decision-making systems such as medical policy, delegated vendors and utilization management with Cotiviti's out-of-the-box library of enterprise connections
  • Accelerate PA decisions, reduce burden and meet compliance SLAs with AI-enabled intake to convert manual fax submissions into compliant FHIR
  • 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 providers)

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