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The CMS Prior Authorization Rule: Opportunities for Automation and AI

Jul 10, 2024
1:00 pm EDT
Presented by MCG
Register Now Registration takes place at a third-party website.

About This Webinar

Integrating artificial intelligence (AI) with enhanced interoperability in the health care industry transforms the prior authorization process, mainly through managing and analyzing unstructured data. When combined with seamless data exchange in alignment with the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), AI's capabilities enable transparency, data exchange, and automation of various tasks within the authorization workflow.

MCG Health has accumulated extensive insights over the last three years through numerous implementations, mainly focusing on the complexities encountered in processing prior authorization transactions from providers to payers. This process encompasses several critical stages: verifying patient eligibility, understanding specific benefits, conducting provider lookups, and creating cases in the payer's utilization management (UM) system. Each stage presents unique challenges, often exacerbated by the disparate systems and protocols used by payers and providers.

By leveraging AI, interoperability, and the power to process unstructured data, the health care system is moving towards a more interconnected, intelligent, and patient-centric model.

Attendees Will Learn About

  • The Impact of CMS's Prior Authorization Final Rule: Gain insights into how the CMS Prior Authorization API and state-led initiatives are transforming the prior authorization landscape in health care, focusing on the efficiency and streamlining of processes.
  • The Role of AI and Interoperability: Delve into the integration of artificial intelligence and interoperability in health care. Understand how this combination effectively manages structured and unstructured data, reduces administrative burdens, accelerates processing times, and promotes a more patient-centric health care model.


Rajesh “Raj” Godavarthi

Associate Vice President, Technology & Interoperability

MCG Health

Raj Godavarthi joined MCG Health in 2003 and oversees a team that builds critical interoperability solutions. Mr. Godavarthi is MCG’s primary representative in the HL7 Da Vinci Project. He has led efforts to support industry stakeholders in developing new HL7 FHIR standards which will allow for improved interoperability and communication between payers and providers. He is also a member of the…

Learn more about Rajesh “Raj” Godavarthi

Daniel Cawood

Senior Product Manager, Interoperability Solutions

MCG Health

Daniel Cawood oversees the product development for MCG Health’s interoperability solutions as well as connecting payers and providers for authorization processes. Mr. Cawood began his time at MCG, focusing on the Indicia suite of solutions (provider market clinical decision support) and value-based care solutions. Before joining MCG, he was a Product Owner for Research & Development…

Learn more about Daniel Cawood