Solutions
Every delayed prior authorization is a patient waiting for care they need. A clinician stuck on hold. A payer buried in manual reviews.
Orchestral delivers prior authorization decisions in under 10 seconds where the industry standard is 72 hours. Built on FHIR, fully compliant with CMS-0057, and ready to deploy alongside your existing systems.
A patient needs an MRI. Their clinician orders it. And then everything stops.
The provider calls the payer. Faxes clinical notes. Waits days for a response. Meanwhile, the patient is left in limbo, their care plan on hold, and administrative costs pile up on both sides.
Prior authorization was designed to ensure appropriate care. In practice, it has become one of the most operationally complex and resource-intensive processes in healthcare. Manual workflows, siloed data, and inconsistent policy interpretation create friction at every stage.
With CMS-0057 now in effect, the bar has risen: payers must meet strict turnaround times, deliver specific denial reasons, and stand up FHIR-based APIs. The question is no longer whether to modernize PA. It is how fast you can get there.
Orchestral’s healthcare intelligence stack provides the foundation to build and deploy prior authorization solutions that go beyond compliance. It turns a broken process into an immediate, auditable decision.
| Challenge | Platform capability | How it works |
|---|---|---|
| Policies trapped in PDFs | AI Design + HIP | NLP and knowledge graphs extract coverage rules from unstructured documents into machine-executable logic. |
| Clinical-to-billing code gaps | HAL + HAT | Semantic matching translates SNOMED/LOINC to CPT/HCPCS with clinical context. |
| Generic denial codes | AI runtime | LLMs grounded in policy generate patient-specific, audit-ready denial rationales. |
| Brittle auto-adjudication | AI runtime + monitoring | ML scoring auto-approves clear cases, routes complex ones to human review. |
| Siloed data systems | HIP data pipelines | Ingest from claims, clinical, UM, and identity systems into a unified FHIR-ready layer. |
| Policies change constantly | HIP + monitoring | Change detection, versioned policy stores, and automated re-validation workflows. |
Payers face the sharpest edge of CMS-0057. New turnaround mandates, specific denial requirements, and four FHIR APIs to build and maintain. Orchestral turns that compliance burden into operational advantage.
CMS mandates PA decisions within 72 hours for urgent requests and 7 calendar days for standard. Orchestral’s HAL delivers decisions in under 10 seconds. Payer policy is matched against clinical evidence in real time, returning an immediate, auditable decision before the clinician leaves the screen.
Authorization rules are loaded directly into HAL. When a PA request arrives, it is matched against policy instantly, consistently, and with a complete audit trail. No manual interpretation. No variation between reviewers.
HAL returns denial reasons tied to the exact policy criteria that were not met. Never generic error codes. CMS requires this. HAL makes it automatic and audit-ready.
HAL builds and operates all four FHIR APIs required by CMS: Patient Access, Provider Access, Prior Authorization, and Payer-to-Payer. Fully conformant with HL7 FHIR R4 and Da Vinci implementation guides.
Built-in dashboards capture PA volume, decision rates, turnaround times, and denial reasons. CMS annual metrics submissions and public disclosure reports are generated automatically.
For clinicians, prior authorization means paperwork, phone queues, and delayed care. For health systems, it means administrative cost and patient dissatisfaction. Orchestral eliminates the friction.
NLP pulls, normalizes, and codifies evidence from EMR and HIE sources into submission-ready FHIR formats. No manual data entry. No re-keying clinical notes into payer portals.
ML models surface denial probability at order entry, with decision support to strengthen documentation or choose alternatives before submission. Fewer first-pass denials. Less rework.
Auto-drafted appeal letters and plain-language PA status updates for patients. Clinicians stay focused on care, not paperwork.
Today, every provider integrates separately with every payer. Payers build four FHIR APIs from scratch, independently. Inconsistent rules are applied differently each time. PA takes days. Care is delayed.
Orchestral changes this by positioning the Health Information Exchange as a neutral broker. Clinical data flows in from one side, payer policy flows in from the other. HAL matches them inside the HIE, and the decision comes back in seconds.
Providers connect to the HIE once and instantly reach every payer on the network.
Payers load their policy into HAL once and every PA is evaluated consistently, immediately, at scale.
The HIE earns revenue as the neutral compliance broker: a new line of business, not a cost center.
One connection replaces the N-by-M direct integration problem.
The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) imposes binding requirements on Medicare Advantage, Medicaid/CHIP, managed care plans, and QHP issuers. Providers in MIPS must also comply. Three deadlines are already in motion:
72-hour urgent and 7-day standard PA turnaround. Specific denial reasons required. API metrics reporting begins.
First public PA metrics due: approval/denial rates, decision times, and appeals outcomes.
Four FHIR-based APIs live in production. Non-compliance impacts payments and Star Ratings.
Build and maintain four FHIR APIs: Patient Access, Provider Access, Prior Authorization, and Payer-to-Payer.
Return PA decisions within 72 hours (urgent) or 7 calendar days (standard).
Provide specific, clinically grounded denial reasons.
Report Patient Access API usage metrics to CMS annually.
Publish PA performance metrics publicly each year (first due March 31, 2026).
Submit at least one electronic PA request per year (MIPS requirement).
Integrate EHR systems with FHIR-based PA workflows (CRD, DTR, PAS).
Package clinical evidence in structured FHIR formats for electronic submission.
Built from 30 years of healthcare infrastructure. Not a general-purpose cloud tool adapted for healthcare.
HIP, HAL, and HAT work as one ecosystem. Data, AI, and orchestration are integrated, not bolted together.
Modular architecture means you can start with the highest-impact capability and expand from there. HAL sits alongside your existing claims and MMIS systems as a compliance layer. One API integration. No rip-and-replace.
Proven at statewide Health Data Utility scale.
We work with your team to scope, configure, and deploy PA capabilities that fit your existing systems and processes.
January 2027 API mandates are less than 12 months away. Every month of delay compounds cost and risk.