Modernizing prior authorization with athenaPayer®

How direct payer integration streamlines electronic prior authorization approvals and reduces delays at scale

Medical prior authorization is one of the most widely acknowledged pain points in healthcare, affecting providers, members, and payers. Evolving from utilization reviews in the 1960s, pre-authorization was intended to support evidence-based care and cost containment. In practice, it often creates care delays, administrative burden, and operational inefficiencies on all sides.

For payers, the challenge is twofold: ensuring appropriate utilization without creating unnecessary friction and doing so across a highly fragmented provider landscape. athenaPayer addresses this by enabling a scalable, embedded solution that connects directly to the health plan, surfacing each stage of the prior authorization process within provider native workflows. This accelerates and streamlines prior authorization at the source.

Offering direct integration with a network of more than 170,000 providers across the U.S.¹, athenaPayer provides a streamlined path to medical electronic prior authorization. It’s not a portal, a bolt-on, or a patchwork fix. It’s a built-in feature of the clinical workflow that aligns provider behavior with health plan rules from the moment care is ordered.

Where legacy prior authorization processes break down

Even with automation efforts underway, many electronic prior authorization workflows remain siloed and inefficient:

• Providers must leave the EHR to initiate authorizations in a payer portal.
• A lack of insight into whether pre-authorization is required means providers waste time submitting unnecessary requests.
• Submissions are often incomplete, requiring clarification or resubmission.
• Prior authorization rules aren’t visible until after the claim is denied.
• Turnaround times are extended by missing data or misrouted requests.
• Manual reviews consume valuable clinical and operational resources.

The result is a system where patient care is delayed, member satisfaction drops, providers are frustrated, and payer administrative costs increase.

athenaPayer simplifies medical prior authorization for payers and providers by embedding the process directly within the provider’s native EHR workflow in athenaOne®.

A better model: Real-time, EHR-integrated medical prior authorization

Through the Medical Electronic Prior Authorization product, athenaPayer simplifies the experience for payers and providers by embedding the prior authorization process directly within the provider’s native EHR workflow in athenaOne®. This eliminates extra steps and reduces the chance of avoidable errors.

athenaPayer enables faster resolution of pre-authorization requests by:

• Automatically identifying when a service requires prior authorization
• Triggering submission workflows from the moment an order is placed
• Pre-populating authorization requests with accurate patient and clinical data
• Returning status updates and decisions in real time, inside the provider workflow
• Ensuring providers see the correct, plan-specific rules for coverage and documentation

It’s all accomplished through a single, direct connection between the payer and athenaOne. 

Leveraging ADT for better visibility and care coordination

In addition to streamlining prior authorization, athenaPayer surfaces real-time ADT alerts sourced from payers into the clinical workflow, giving providers immediate insight into member movement across care settings. This is especially valuable in complex cases where authorization, discharge planning, and case management are tightly connected.

Incorporating ADT data into the clinical workflow benefits payers and providers by:

• Improving care coordination by providing access to the latest information about members’ health
• Prompting the provider to deliver follow-up care
• Streamlining administrative processes and improving overall efficiency
• Providing transparency into post-discharge care, helping to prevent readmissions

When ADT and prior authorization data are integrated into a single platform, providers gain a more complete picture of their patients' care journey, while payers can better see utilization without waiting on batch feeds or delayed reporting. Connecting payers and providers in this way helps improve both patient safety and quality of care.

athenaPayer benefits for payers

1. Shorter turnaround times: With direct connections and real-time EHR integration, requests move through the process faster and often require less manual review.
    
2. Less administrative overhead: By eliminating phone calls, faxes, and retroactive prior authorization requests, plans can reduce call center volume and operational costs.
    
3. Improved provider compliance: Instead of relying on education, enforcement, or retrospective audits, plans can make it easy for providers to submit complete, documented requests from the start.
    
4. Real-time visibility into care transitions: ADT alerts support better utilization tracking, earlier intervention, and stronger member management strategies.
    
5. Scalable infrastructure: Because athenaPayer connects with over 170,000 providers through a single integration, plans avoid the complexity of one-off onboarding or bespoke builds that serve only one practice or provider at a time.

In short, athenaPayer helps payers manage authorizations more efficiently, proactively, and at scale.

athenaPayer benefits for providers and members

While the operational value is clear, the downstream effects on care delivery are equally important. With athenaPayer:

• Providers no longer leave the EHR to complete electronic prior authorization tasks
• Status updates return directly to the system where care is being managed
• ADT and prior authorization events are surfaced in a unified view
• Fewer delays mean faster access to time-sensitive services
• Patients benefit from a smoother, more predictable care experience

The result is a better experience for both care teams and the members they serve.

Prior authorization modernization that scales

The implementation of medical prior authorization today imposes burdens on payers and providers that interfere with the delivery of care. athenaPayer offers a path forward that simplifies the process for providers while preserving clinical oversight for payers. By delivering real-time prior authorization workflows and ADT notifications directly into provider workflows across a nationally scaled network, athenaPayer helps payers reduce friction, ensure compliance, and move faster — without expanding manual review or infrastructure burden.

Ready to streamline prior authorization and improve care coordination?

Let’s talk about how athenaPayer can help your team reduce turnaround times, improve provider engagement, and better manage member transitions, all while lowering operational costs. Get to know athenaPayer, then reach out to our payer partnerships team to schedule a conversation.