Simplifying utilization Management & CMS ePA Compliance with Coforge Authorization Rules Center

The Prior Authorization process in healthcare is onerous, but the CMS Interoperability final rule mandates automation by January 2026. Coforge’s solution - ARC is a rules engine that centralizes and automates authorization rules, empowering experts to author and maintain them. It offers easy authoring, supportive intelligence, and seamless connectivity through APIs. ARC answers key authorization questions, improving accuracy, auto-authorization rates, and compliance while reducing costs and errors. This solution transforms authorization management, ensuring efficiency and traceability.

The Prior Authorization process is considered one of the most burdensome in healthcare. The CMS Interoperability final rule will affect all government payers as of January 2026, requiring automation in the management of the authorization process.

Today, authorization rules are often maintained manually, codified directly into disparate systems, or not codified at all requiring people to review text to make decisions resulting in high-cost manual touches and errors.

ARC Solution Overview:

ARC is a rules engine delivering a manageable, connected, single source of truth for authorization rules. ARC empowers subject matter experts to directly author and maintain rules and supports them with the intelligent experience needed. ARC then connects to any system needing reference authorization rules and provides them with answers via APIs. In addition to connecting the knowledge holders to the knowledge users, ARC ensures complete traceability of your rules – keeping a full audit history of the rules themselves and how they were used.

Key Features:

• Easy Authoring – Empowers subject matter experts to author rules with dynamic guidance and structure, bulk upload/download, effective and expiration dates, and reusable standard definitions
• Supportive Intelligence – Enables rules conflict identification and an automated testing suite, controlled publication workflows, searchable and exportable rules, complete audit trails, and utilization statistics
• Connectivity – Delivers ready APIs for real time connectivity to any consuming system from Customer Service to External Portals, to UM processing tools, and interoperability standards

What does ARC Do?

• Centralizes authorization rules and puts maintenance directly into the hands of business experts
• Provides responses to three key questions:
  • Does this service require authorization?
  • Can this service be auto authorized?
  • What clinical criteria should be used to review this service?
• Connects rules to consuming systems in real time

Business Benefits:

• Increased ability to connect consumers and improved information accuracy resulting in a reduced number of contacts related to prior authorization
• Improved auto authorization rates resulting in decreased cost
• Reduced rework resulting from inaccurate information or decisions leading to lower costs
• Enhanced compliance and visibility resulting in reduced risk

Conclusion

ARC revolutionizes the Prior Authorization process by centralizing rules and enabling real-time connectivity. Empowering experts to manage and trace rules ensures accuracy and compliance. With ARC, experience reduced costs, improved auto-authorization rates, and enhanced information accuracy. Transform your healthcare operations and reduce burdens with ARC’s intelligent, efficient, and compliant solution.
Ready to streamline your Prior Authorization process? Talk to our experts today and transform your healthcare operations with Coforge ARC!