Availity® Adds Another Large Blues Plan to Growing List of Customers Seeking to Streamline Authorizations

Availity, the nation's largest real-time health information network, successfully implemented its Intelligent Utilization Management, solution with a large regional Blue Cross Blue Shield health plan seeking to deliver near real-time authorization decisioning for its expansive network of providers and members.

The regional health plan is the largest commercial payer in its state. Its decision to modernize the prior authorization experience through Availity’s Intelligent Utilization Management marks one of the most significant payer-led transformations in the region in years.

The health plan implemented Availity Intelligent Utilization Management solution to fulfill several strategic imperatives:

• Automate approvals to providers by evaluating structured clinical data against codified medical policy
• Reduce provider abrasion by increasing transparency and eliminating ambiguity and unnecessary steps, while delivering near real-time recommendations
• Improve decision consistency and auditability with clear policy alignment

Availity expects the results to mirror the outcomes seen by other Availity clients. More than 1.1 million authorizations were submitted through Availity Intelligent Utilization Management between January 2024 and March 2025, spanning diagnostic imaging, cardiology and musculoskeletal cases. Seventy-six percent of those submissions were recommended for approval in near real time, with average response time of under 20 seconds.

“Prior authorization was never meant to delay care,” said a spokesperson from the regional health plan’s leadership team. “By partnering with Availity, we’ve aligned technology, clinical judgment, and policy into one seamless solution—improving patient access and reducing administrative waste.”

Rapid Implementation, Strong Adoption, and Measurable Control

The health plan implemented the full Intelligent Utilization Management platform across high-volume outpatient services, including musculoskeletal, cardiology, and imaging. Most recommendations can be returned in under 90 seconds.

This speed and precision are possible because Availity’s solution extracts clinical information directly from the medical record and uses a proprietary AI engine to analyze it against codified medical policy to determine medical necessity. To streamline the prior authorization processes, utilization management clinicians should be focused on the most complex cases that require their expertise. To do this, they need a better way to identify cases where medical necessity can be easily determined in near real-time with appropriate clinical documentation.

The health plan’s decision to partner with Availity was based on its desire to meet the demands of their provider network and members to deliver a faster and more transparent authorizations process.

Most providers in the state already use Availity for payer engagement, due in part to state mandates. This existing infrastructure enabled a remarkably smooth deployment—completed on time and under budget in just 10 months, shorter than the average 12-18 months of an implementation of this size.

Because Availity serves as a digital front door, providers have just one place to go to submit authorizations and access a comprehensive dashboard that delivers real-time visibility into all authorization statuses.

The health plan sought to reclaim control over a utilization management process that had long been outsourced to delegated vendors. Availity Intelligent Utilization Management supported the integration of the health plan’s preferred clinical content. This level of configurability—integrating the content of their choice with the platform of their choice—was a critical differentiator and a signal of Availity’s flexibility.

Future-Ready and Fully Aligned

The health plan’s deployment of Availity Intelligent Utilization Management positions it well ahead of the January 1, 2027, CMS Interoperability and Prior Authorization Final Rule deadline. With Fast Healthcare Interoperability Resources (FHIR)® APIs and bi-directional connectivity already in place through Availity, the plan is not just compliant—it’s future-ready.

“Our clients want to do more than comply with the CMS final rule,” said Russ Thomas, CEO of Availity. “They want a smarter, more sustainable UM program that supports providers, improves member experience, and ensures that medical necessity is determined quickly, consistently, and fairly.”

About Availity

Availity is the trusted partner for organizations seeking to realize the greatest value from clinical, administrative, and financial information. Positioned at the nexus of provider, health plan, and consumer health information, Availity develops scalable, innovative solutions for healthcare data acquisition, standardization, transparency, automation, and exchange among health plans, providers, and technology partners. As one of the nation's largest health information networks, Availity facilitates billions of clinical, administrative, and financial transactions annually. Our suite of dynamic products, built on a powerful, intelligent platform, enables real-time collaboration for success in a competitive, healthcare ecosystem.

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