Data & Interoperability
Make payer data usable for AI and automation
Provider data, member data, master data, FHIR, APIs, semantic consistency, integration, and context access.
Health Plans
AI, data, workflow and Decision Control for health plans
Health plans are applying AI and automation across workflows where fragmented data, policy requirements, operational complexity, human review, and consequential payer actions determine whether the economics actually work. GNS-AI helps health plans design, implement, evaluate, govern, and control those systems.
Chief AI, CIO, CTO, data and analytics leadership, utilization management, prior authorization, claims and payment operations, provider and network operations, member operations, Responsible AI, governance, risk, and compliance.
Built for payer operations.Hospitals and health systems: see the Hospitals & Health Systems page.
Capability areas
Where GNS-AI works with health plans.
Work spans data, workflow, AI implementation, validation and governance, and Decision Control where AI influences consequential payer actions.
Workflow & Automation
Operate where the economics are decided
Prior authorization, utilization management, claims, payment integrity, provider operations, member operations, care management, and network operations.
AI Strategy, Build & Validation
Design and prove AI that can scale
AI architecture, implementation, pilot design, pilot evaluation, and scale readiness.
Responsible AI & AI Governance
Keep production AI accountable
Validation, accountability, oversight, and production governance.
Decision Control
Control consequential payer actions
DCP is relevant where AI materially influences consequential payer actions and the plan needs to determine where AI is sufficiently supported, what level of responsibility is justified, how much control is economically appropriate, and why that authority was applied.
Why now
CMS-0057-F is already an operating priority for impacted payers.
CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) sets process requirements that generally began January 1, 2026, and API requirements that generally begin January 1, 2027. Exact dates vary by payer type. This is timing context, not legal advice.
2026 process provisions
Decision timeframes, denial reasons, and metrics
Impacted payers generally must meet certain operational prior authorization provisions beginning January 1, 2026, including decision timeframes for most payer types, specific denial reasons, and public prior authorization metrics (initial metrics by March 31, 2026 per CMS).
2027 API requirements
Patient Access, Provider Access, Payer-to-Payer, Prior Authorization APIs
Major API development and enhancement requirements are generally due beginning January 1, 2027, with timing that varies for MA, Medicaid and CHIP FFS, managed care, and QHP issuers on FFEs.
The business bridge
Electronic PA is not the same as operating value
As prior authorization becomes more electronic and automated, health plans still have to determine where automation removes work, where human review remains necessary, and which AI investments create measurable operating value.
CMS fact sheet: CMS-0057-F · Prior authorization application
Flagship path
Prior authorization as a consequential payer workflow.
Prior authorization is a primary path for health plans that need Decision Control where AI influence accumulates before a proposed payer action.
How to buy
Start with the operating constraint.
Public entry points for health-plan buyers. Other engagements are scoped.
Should we do it?
AI Initiative Review
$3,500 fixed · 5 business days. A bounded review of an AI, automation, workflow, or data initiative before more capital is committed.
See the Initiative ReviewDid it actually work?
Pilot Efficacy & Scale Readiness
Evaluate whether a pilot created enough real-world value and efficacy to justify scale.
See Pilot EvaluationWhen control is the question
Decision Control Assessment
3-4 weeks · Starts at $30,000 · Typical $30,000-$45,000. Evaluate one consequential workflow to determine where AI is creating value, where responsibility can expand, what level of control is appropriate, and whether persistent Decision Control is warranted.
See the AssessmentWhen persistent control is warranted
Decision Control Plane
Persistent runtime Decision Control for consequential AI workflows. Scoped.
See DCPRelated markets
Health plans are distinct from care delivery, devices, and federal work.
Hospital and health-system buyers should use Hospitals & Health Systems. Device and digital-health buyers should use Medical Devices & Digital Health. Agency buyers should use Federal & Public Sector.
Next step
Have a health-plan AI workflow where value or control is getting stuck?
Bring an initiative that is unclear, a workflow to automate, a pilot that has not proven its value, or a process where review burden is eroding the economics. The fit call routes to the smallest appropriate paid engagement, or to no engagement.