Prior authorization remains one of the most persistent sources of friction in U.S. healthcare. Manual workflows, fragmented systems, and unstructured medical policies slow care delivery, increase administrative burden, and create unnecessary costs for payers and providers alike.
That challenge was front and center during a recent WEDI Virtual Spotlight, “How to Power Electronic Prior Authorizations Through an Integrated Data and AI Solution”, sponsored by 1upHealth. The session brought together leaders from 1upHealth and GenHealth.ai to explore how standards-based interoperability and AI-driven automation can work together to modernize prior authorization ahead of the CMS-0057 January 1, 2027 deadline.
Why Prior Authorization Needs a New Approach
The industry is under pressure to meet new federal and state interoperability requirements, while still operating in a reality shaped by legacy tools like fax, portals, and PDFs. As the speakers emphasized, prior authorization success depends on two things working in tandem:
- Standardization through FHIR APIs to enable consistent, scalable exchange
- Speed and automation to meet increasingly strict turnaround times and reduce burden
FHIR alone solves only part of the problem. Many medical policies remain complex, narrative, and difficult to codify. This is where AI becomes a force multiplier.
1upHealth’s Modular Electronic Prior Authorization Approach
Jeremy Yoon, Senior Product Manager at 1upHealth, opened the session with an overview of how 1upHealth enables electronic prior authorization as part of a single, integrated interoperability platform.
For CMS-0057, 1upHealth supports full compliance across all required access APIs, including Patient Access, Provider Access, Payer-to-Payer Data Exchange, and Prior Authorization APIs. Rather than forcing a one-size-fits-all model, 1upHealth’s approach is modular by design, recognizing the diversity of payer ecosystems and vendor landscapes.
Key capabilities highlighted included:
- CRD, DTR, and PAS APIs built on Da Vinci FHIR standards
- Intelligent routing that directs authorization requests to the correct downstream systems
- Real-time coverage discovery, eligibility checks, and documentation requirement
- Provider registration and education tools to support adoption
- Reporting and analytics to meet public reporting requirements
- Real-time data streams that can power member and payer experiences
The result is a flexible interoperability layer that connects EHRs, payer systems, and authorization vendors while exposing data for future use cases.
GenHealth.ai’s AI-Driven Adjudication Engine
Ricky Sahu, CEO of GenHealth.ai and founder of 1upHealth, walked through how GenHealth.ai applies AI to automate the most time consuming and complex aspects of prior authorization.
GenHealth.ai’s platform is built on three core technologies:
- A large medical model trained on claims data from over 140 million patients to predict care pathways, utilization, and outcomes.
- An adjudication agent that converts unstructured medical policies into structured decision trees and FHIR questionnaires.
- Browser-based AI agents that operate existing portals and applications the same way humans do today.
This approach allows plans and providers to automate prior authorization even when APIs are incomplete or unavailable. Policies can be ingested directly from PDFs or web pages, transformed into logic-driven questionnaires, and adjudicated using both structured and unstructured clinical data.
As Ricky noted, tasks that once took hours or months can now be completed in minutes or days, dramatically accelerating implementation timelines.
Bridging Electronic Prior Authorization Standards and Reality
A key theme throughout the session was the need to bridge ideal standards-based workflows with real world constraints.
FHIR enables consistency and scale, but not every clinical or policy question can be answered with codes alone. AI fills that gap by interpreting narrative clinical notes, policy language, and context that would otherwise require manual review.
Together, 1upHealth and GenHealth.ai demonstrated how standards and AI are not competing approaches, but complementary ones. The combination enables automation for simple cases while still supporting complex, high-value scenarios that demand deeper clinical reasoning.
A Live Look at Prior Authorization in Action
The session concluded with a live demonstration showing two workflows inside a mock EHR:
- A standard CRD and DTR flow powered entirely by 1upHealth
- A complex bariatric surgery prior authorization routed to GenHealth for AI-driven questionnaire generation and adjudication
Attendees saw how policy-sourced questionnaires, citation-backed decision logic, and human oversight can come together to deliver faster, more accurate outcomes. In many cases, plans using AI-driven adjudication are seeing reductions of 60 to 80 percent in administrative workload.
More importantly, faster decisions translate directly into faster access to care for patients.
Watch the Full Prior Authorization Webinar
The CMS-0057 deadline is approaching quickly, and prior authorization remains one of the most operationally complex requirements to implement. This WEDI Virtual Spotlight offers a clear, practical view into how payers can combine FHIR interoperability and AI automation to meet regulatory requirements while reducing cost and friction.Watch the full webinar recording to see the demo and discussion in detail and learn how integrated data and AI can transform prior authorization.