What AHIP's 80% real-time approval target actually requires from health plans

By 2027, AHIP mandates that 80% of electronic prior authorization requests receive real-time answers. Sustainable success won't come from automating the most cases, but from automating the right ones. The distinction between volume and selectivity is what separates an approach that just hits the number from a strategy that holds up over time.

Selectivity is a clinical decision

Every health plan has a different authorization population, shaped by its line-of-business mix, provider network dynamics, historical utilization patterns, and existing policy frameworks. The cases eligible for real-time approval in one plan's commercial book may differ from those in another's Medicare Advantage population.

This means the primary question isn't "How do we automate faster?", but "Which authorizations align with medical necessity criteria and evidence-based policy to support real-time decisions–and how do we maintain that standard consistently?" Without clinical intelligence, automation is just rubber-stamping. The role of AI is to apply clinical context and judgment consistently at scale, in line with the strategy defined in the plan.

Plans that skip this step–that layer automation broadly across service types to move fast–tend to see one of two outcomes. The first: approvals go up, but so does utilization, quietly eroding the medical expense discipline the plan depends on. The second: clinical reviews surface patterns that require automation to be pulled back, leaving the plan further from the AHIP target than when they started, and with less time to close the gap. Neither approach offers a sustainable path to meeting the 80% compliance target.

What a thoughtful authorization population looks like

Defining the right cases for real-time approval requires evaluating multiple dimensions simultaneously: the strength of clinical evidence, policy alignment, and regulatory requirements by line of business.

Services that pose low risk to patient safety, carry higher risk if care is delayed, and are supported by clear, evidence-based clinical criteria can support higher automation targets. Standard services where appropriateness depends on clinical documentation supporting the request require more sophisticated policy logic to enable safe real-time decisions. Higher-cost procedures or treatments where clinical review adds genuine protective value warrant a more conservative posture–still contributing to the 80% target, but with appropriate clinical oversight in place.

The goal isn't to find every case that could be automated. It's to confidently identify the ones that should be, and to build the infrastructure to keep that population accurate as clinical patterns evolve.

A clinically grounded approach to real-time approvals

Knowing which cases should be automated is only the starting point.

It requires a clinically grounded approach, one that combines advanced, precision AI with deep clinical expertise. Done well, this approach reinforces the integrity of the entire authorization process. The right cases move through instantly, while more complex or uncertain scenarios are intentionally routed for review, preserving both clinical rigor and cost discipline.

At Cohere Health, our work with health plans to build these programs is grounded in core principles that prioritize patient safety, clinical integrity, and provider collaboration. Our framework ensures that administrative efficiency doesn't come at the expense of appropriate care. Instead, we strengthen the entire utilization management program by enhancing evidence alignment, policy clarity, and the provider experience.

These principles, and our approach, are explored in detail in the full white paper.

The timeline is closer than it looks

2027 feels distant, but it isn't. Building a clinically grounded automation program by aligning criteria, configuring PAL designs, establishing model baselines, and validating performance across business lines requires more time than typical technology project timelines allow.

The health plans in the best position by 2027 are the ones that started with the selectivity question now, before the pressure to move fast crowds out the space to move carefully. There's still time to do both, but that window narrows the longer the foundational clinical work gets deferred.

If you want to define the right 80 percent for your organization, we have the resources to help. Our new white paper provides a practical framework to help health plan executives and clinical leaders implement these changes effectively. You'll learn how to define your eligible authorization population, sequence automation across various service types, and manage medical expenses as your approval rates increase.

By laying the groundwork today, you can build an automation program that is not only efficient but also clinically sound, setting your organization up for long-term success.

Ready to define the right 80%?‍

Download the full white paper for the complete clinical frameworks, five-principle methodology, and implementation guidance tailored to where your plan stands today.