Data Sheet: Transforming Utilization Management with an AI-Powered Decision Intelligence Ecosystem

Transforming Utilization Management with an AI-Powered Decision Intelligence Ecosystem

Health plans face significant and persistent challenges in prior authorization management, including high administrative costs, care delivery delays, complex regulations, and immense pressure on clinical staff. To address these issues, HealthEdge GuidingCare® introduces a first-of-its-kind AI-Powered Decision Intelligence Ecosystem. This platform enables health plans to leverage best-in-class AI capabilities, transitioning from manual, fragmented workflows to agile, intelligent automation.

This AI-first strategy for clinical intelligence and care management optimization empowers payers to enhance efficiency, accuracy, and compliance. Learn more about how AI is transforming utilization management and how your organization can benefit.

Addressing Critical Challenges in Prior Authorization

Traditional prior authorization processes are a source of friction for members, providers, and payers. The market's most critical challenges include:

• High Costs: Prior authorizations contribute to approximately $35 billion in annual U.S. healthcare administrative spending.

• Delays in Care Delivery: Time-consuming manual reviews lead to significant care delays for 94% of patients, with 78% abandoning treatment altogether.

• Complex and Evolving Regulations: New standards, such as CMS-0057-F, mandate faster, more transparent prior authorizations. Health plans require auditable solutions to ensure compliance, which presents a strategic opportunity for payers.

• Pressure on Clinical Staff: High volumes of repetitive administrative work limit the time clinicians can dedicate to complex, high-touch cases that require their expertise.

Core Benefits of the GuidingCare® Ecosystem

With the GuidingCare® AI-Powered Decision Intelligence Ecosystem, health plans can achieve significant operational improvements and measurable results. The platform is built to deliver value across the entire utilization management lifecycle.

Key Platform Advantages

• Seamless Platform Integration: The ecosystem connects with core UM systems via secure APIs, ensuring implementation excellence and minimal operational disruption. Explore our integration capabilities in the GuidingCare API Catalog.

• Advanced Decision Intelligence: Access proprietary AI models from industry-leading partners that leverage payer-specific clinical policies, guidelines, and business rules to support consistent and accurate determinations.

• Transparent, Auditable Workflows: Every automated decision generates a clear and comprehensive audit trail, supporting regulatory compliance and internal policy governance.

• Integrated Automation: Streamline and automate prior authorization intake, evaluation, and decision-making. This reduces the average processing time per case and improves efficiency for both the utilization management team and providers using the authorization portal.

By future-proofing your health plan with GuidingCare® FHIR Solutions, you can ensure interoperability and compliance are at the core of your AI integration strategy.

A Connected Ecosystem of Leading AI Solution Partners

GuidingCare® collaborates with industry-leading solution partners to deliver integrated workflows that optimize health plan operations. By integrating with best-in-class vendors, we provide clients with advanced AI capabilities that drive automation and efficiency.

Unlock the Next Generation of Utilization Management

Embrace a strategic, scalable, and intelligent approach to automation across your prior authorization workflows. The GuidingCare® AI-Powered Decision Intelligence Ecosystem empowers your health plan to achieve measurable results, improve satisfaction, and reallocate valuable clinical resources to complex care.

To learn more about modernizing prior authorization for health plans and to see how our ecosystem can transform your operations, connect with our team today. You can also discover how to enhance your health plan technology systems with an optimization assessment.