CMS prior auth rules take effect 2026 — is your plan ready? Check your readiness →

Built for managed care organizations

AI-Powered Utilization Review.
Minutes, Not Days.

Replace manual prior authorization reviews with clinical AI that reads charts, applies medical necessity criteria, and routes decisions in minutes instead of days.

Try Live Demo Request a Demo
90%
Auto-Approval Rate
8-12wk
Onboarding Timeline
70%
Cost Reduction
$2.4M
Avg Annual Savings
Platform

Three engines. One clinical workflow.

CareHive replaces fragmented UM tools with a unified platform that automates decisions, prioritizes cases, and maintains full regulatory compliance.

AI Auto-Review

Intelligent analysis of authorization requests against clinical criteria including InterQual, MCG, and ASAM guidelines. The AI reads submitted documentation, extracts clinical indicators, and generates approval or escalation recommendations with cited evidence.

InterQual / MCG / ASAM

Smart Queue

Cases are priority-ranked by clinical risk score, regulatory turnaround deadlines, and urgency indicators. Reviewers see the highest-impact cases first. No more digging through inboxes or spreadsheets to find what matters.

Risk-scored routing

Clinical Workflow

Approve, escalate to peer review, or deny with structured rationale. Every action generates a timestamped audit trail with clinical justification, reviewer identity, and criteria references. Built for NCQA and CMS compliance.

Full audit trail
Workflow

Three steps. Twelve minutes.

From submission to decision, CareHive compresses a multi-day manual process into a structured, auditable workflow.

01

Submit Auth Request

Provider submits a prior authorization via FHIR API, portal upload, or fax-to-digital intake. Clinical documents, diagnosis codes, and procedure details are extracted automatically.

Passes to AI engine
02

AI Analyzes Against Criteria

CareHive's clinical AI evaluates the request against your configured medical necessity guidelines. It identifies supporting evidence, flags gaps, and generates a structured recommendation with confidence scoring.

Routes to reviewer
03

Reviewer Decides

High-confidence approvals are auto-processed. Complex cases appear in the smart queue with AI-generated summaries, cited criteria, and one-click approve/deny/escalate actions. The reviewer makes the final call with full context.

Pricing

Transparent pricing. No surprises.

Flat annual fee based on member count. No per-review charges, no hidden fees. Includes full platform access, onboarding, and ongoing support.

Tier 1
100K – 250K members
$60K/yr
Billed annually
  • Full AI auto-review engine
  • Smart queue + clinical workflow
  • NCQA & CMS compliant audit trail
  • Dedicated onboarding (8-12 weeks)
  • Email & Slack support
Request Demo
Tier 2
250K – 500K members
$120K/yr
Billed annually
  • Everything in Tier 1
  • Priority support + SLA
  • Custom clinical criteria config
  • FHIR API integration support
  • Quarterly business reviews
Request Demo

Custom pricing available for plans with 500K+ members. Contact us

ROI Calculator

See your savings before the first call.

Built for the internal justification conversation. Drag the sliders and get numbers your CFO will believe.

Your Organization
Members managed 150,000
50K 500K
UR review staff (FTEs)
FTEs (range: 5–50)
Avg review processing time 30 min
15 min 60 min
Cost per review $42.50
Auto-calculated from staff rate ($85/hr) Override
Your Projected Returns
Projected annual savings
$1,240,000
Based on 70% automation of routine reviews
Staff hours recovered / year
14,560 hrs
≈ 7.3 FTEs redirected to complex cases
Cost per review — before vs. after
Before
$42.50
After CareHive
$12.75
Estimated break-even timeline
1.4 months
At $60K/yr tier (Tier 1)
CMS 2026 compliance readiness
84%
With CareHive: 97% automation-ready
Pre-fills your demo request with these numbers
CMS 2026 Readiness

How ready is your plan for
CMS 2026 prior auth rules?

Self-assess your organization against the 10 key requirements. See where your gaps are — and how CareHive closes them automatically.

Prior auth decisions within 24 hours for urgent requests
CMS requires urgent prior auth decisions within 1 business day
Rule §422.568
Standard prior auth decisions within 72 hours
All non-urgent prior auth determinations within 3 business days
Rule §422.568
Real-time prior auth status updates to providers
Providers must be able to check authorization status electronically in real time
Technology
Publicly reported prior auth approval/denial rates
Annual public reporting of prior auth volume, approvals, denials, and appeal rates
Transparency
Electronic prior auth via FHIR API (HIPAA CDex)
API-based submission and retrieval of prior auth requests per HL7 FHIR R4
Technology
Specific denial reasons in plain language
Every denial must include clear reasoning and clinical basis in plain, non-technical language
Rule §422.566
Expedited appeals process for urgent denials
Appeals for urgent requests must be resolved within 72 hours of receipt
Rule §422.572
Continuity of care during plan transitions
Ongoing treatment authorizations must be honored during enrollment transitions
Rule §422.111
Formulary exception decisions within 24 hours (urgent)
Exception requests for formulary drugs must meet the same timing requirements as prior auth
Rule §423.578
Complete audit trail for CMS compliance reviews
Every authorization decision must be logged with timestamps, decision criteria, and reviewer identity
Technology
Your CMS 2026 Readiness Score 0%
Check the items your organization currently meets.

🔒 See your full results + compliance gap analysis

Enter your work email to unlock all 10 checklist items and get a personalized CMS 2026 readiness report sent to your inbox.

Your plan scores — ready. Here's what CareHive automates:
    See CareHive handle each gap

    See CareHive in action.
    Request a demo.

    Get a personalized walkthrough of the platform with your team. We'll show you how CareHive handles your specific auth volumes and clinical criteria.

    • 30-minute personalized walkthrough
    • See AI auto-review on real case types
    • Custom ROI estimate for your plan
    • Response within 24 hours