-
Platform
-
Solutions
-
Customers
-
-
Resources
-
Company
Next time, try CTRL + K to open the search
For a Medicare Advantage plan, half a star is worth billions of dollars. Plans rated four stars and above qualify for quality bonus payments from CMS, and those payments are expected to top $13 billion across the industry this year. Investors now treat a plan's rating as a core measure of its financial health.
Most of the conversation about Star Ratings focuses on clinical quality: flu shots, screenings, and medication adherence. But a large share of the 40-plus measures comes down to something more basic: How quickly and accurately does the plan handle what members and providers send it?
That work starts at the front door. Every coverage question, prior authorization, appeal, and grievance is a request that has to be read, understood, routed, and resolved on the clock. When intake breaks, member experience breaks with it.
Where member experience breaks
Many health plans already capture documents digitally. The work of classifying, interpreting, and routing requests didn’t go away; it moved downstream. Requests still arrive through disparate channels, and people still determine what each request is, what action it requires, and where it should go.
- Channels are disconnected from systems. Faxes, phone notes, portal messages, and letters arrive with no common queue and no shared view of status.
- Triage is done by hand. A letter could be an appeal, a grievance, a coverage question, or a complaint. Someone has to read it, look up the member, and check policy before it can move.
- Data is re-keyed. Details are typed into claims, care management, and CRM systems by hand, which adds errors and delay.
Each of these gaps affects the member experience. A coverage question that waits two days for the right team becomes a second phone call. A misclassified letter can trigger the wrong processing deadline, or none at all. A missed deadline becomes a complaint, auto-forwarded appeal, or audit finding.
Less time to get it right
The deadlines that govern health plan intake are tightening, and more of the results are public.
Request | Deadline (Medicare Advantage) | What happens when it slips |
Prior authorization | 72 hours expedited, seven days standard, under CMS-0057-F since January 1, 2026 | Incomplete requests burn time waiting for records |
Reconsideration (appeal) | 72 hours expedited, 30 days standard pre-service, under 42 CFR 422.590 | The case auto-forwards to the independent review entity |
Grievance | 24 hours expedited, 30 days standard, under 42 CFR 422 Subpart M | Timeliness is reviewed in CMS program audits |
The cost of manual work compounds the problem. A manual prior authorization costs a health plan $3.41, compared with $0.05 for an electronic one, according to the 2025 CAQH Index. And in 2024, 80.7% of appealed prior authorization denials in Medicare Advantage were overturned, according to KFF. Every one of those overturns is rework on a decision that did not hold.
What intelligent intake does
Intelligent intake turns every incoming prior authorization request, appeal, or grievance into an automated process, from arrival to triage. It works in four steps, with people in the loop where judgment matters:
- Capture. Read the request from any channel, classify it, and extract the details. Fax, phone notes, portal, mail, and API traffic land in one queue, so no one re-keys a request.
- Correlate. Check the request against member records, history, and current policy across the systems that hold them. No one swivels between multiple screens to assemble the facts.
- Decide. Apply routing rules to the clear cases. Where inputs vary, an AI agent assesses the item and recommends a path. Where the call needs clinical or regulatory judgment, it goes to a person with the facts attached and the right clock already running.
- Persist. Write the data and the decision back to the systems of record, with a log of who did what, when, and why.
AI makes each step faster and more accurate, but the real value comes from orchestrating the entire workflow across claims, care management, and CRM systems a health plan already uses.
How one US national health plan put it to work
A large US national health plan put member experience at the heart of its technology roadmap. On the Appian Platform, teams built applications for enrollment, call center outreach, pharmacy operations, and more, with dozens of additional applications planned over the next two years. They achieved:
- Enrollment at scale. Appian orchestrates the workflow behind the plan's member-facing enrollment tools. In a recent run, the plan enrolled 21,000 Medicaid members across 10 states in a couple of hours. The same work used to take from four days to a week. Of those enrollments, 99.5% passed through without a human touch.
- Call center outreach with real-time value tracking. In the plan's pharmacy business, Appian supports call center outreach and lead follow-up. Value dashboards built into the application show operational leaders, in real time, how the work is tracking against the milestones they are accountable for.
- Specialty prescriptions on a one-hour clock. The plan is now applying the same intake pattern to specialty prescriptions. Some of these medications cost millions of dollars per dose, and for some members a delay is a matter of life and death. Approvals may be required within 15 minutes to an hour. That is an intake and triage problem: read the request, match it to the member and the criteria, and route it to the right reviewer before the clock runs out.
While these operational wins show the same intake and orchestration pattern at scale, they directly strengthen the core workflows that drive Star Ratings: delivering fast, accurate answers and reducing repeat calls.
Where to start
The first use case is the hardest. But once channels are connected, systems are integrated, and policies are encoded, every additional workflow becomes faster and easier to implement. Three questions can help a health plan identify where to start:
- For utilization management: What share of prior authorization requests still arrive by fax, and how much of the clock is gone before a nurse opens one?
- For appeals and grievances: How long does a letter sit before someone decides whether it is an appeal, a grievance, or a coverage question?
- For the call center: When a member call escalates into a complaint, does the grievance team get the call record and member history, or start from scratch?
Pick the one with the most volume and the tightest clock. Start with one channel or queue, prove the result, and then ask where else work arrives the same way.
The front door is where trust is built
Members care about getting clear answers to their questions, having prescriptions approved on time, and not having to explain themselves twice. Health plans that orchestrate intake from the first point of contact through final resolution protect the outcomes that depend on getting each step right.
By embedding AI directly into the processes where work gets done, Appian helps health plans move every request toward a resolution.
