ARC: Authorization Rules Engine for Healthcare

The Prior Authorization process is considered one of the most burdensome in healthcare. Industry and CMS attention are at a peak. 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.

Result

• High-cost manual touches.
• Inaccurate information and inconsistent decisions lead to rework.
• Low satisfaction among providers, members, and internal staff.
• Reduced ability to scale and innovate.

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 they need to do it flawlessly.
• 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.

Business Benefits

• Increased ability to connect consumers and increased 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.