As a new federal administration sets its sights on modifying Medicaid programs, Medicaid health plans are bracing for significant change.  

July 31, 2025:  New regulation, officially named the Health Data, Technology, and Interoperability: Electronic Prescribing, Real-Time Prescription Benefit and Electronic Prior Authorization final rule was released. On prior authorization, the regulation adopts three new criteria: one that allows providers to request information from payers about coverage requirements, another that offers a method for clinicians and other EHR users to quickly collect the data needed for a prior authorization request, and a third that allows providers to submit requests through their IT systems and check the request’s status. 

According to CMS by the end of this calendar year the prior authorization process will be significantly better for health care providers and patients with the new policies. There are six key parts of a pledge to cut red tape out of the UM process:

1. Standardize electronic prior authorization submissions
2. Reduce the number of medical services that require prior authorization
3. Honor existing authorizations when patients change insurance plans 
4. Enhance transparency and communication about authorization decisions and appeals
5. Minimize delays with real-time approvals 
6. Ensure medical professionals review all clinical denials

Additionally, staffing shortages, rising medical inflation, and increasing claim volumes are creating additional challenges for many Medicaid health plans. 

WNS-HealthHelp’s AI-powered UM ecosystem addresses both regulatory and market challenges head-on by reducing manual work, lowering denial rates, and streamlining provider interactions. Our transformative model is designed specifically for the realities faced by Medicaid health plans with a solution that is affordable, AI-enabled, flexible, and clinically rigorous.

A Smarter Policy-Aligned UM Approach, Taking Medicaid into the Future

Medicaid populations are unique and so are the challenges they bring. From diverse clinical needs to tighter budgets and stricter compliance mandates, Medicaid health plans require a UM partner that goes beyond a one-size-fits-all solution and meets them where they are.

WNS-HealthHelp delivers just that. Our next-generation Medicaid UM platform is designed around 5 core principles that are also the focus of DHHS in the coming year. 

1. AI-Enhanced: By automating routine prior authorizations to get to approvals faster and leveraging virtual care coordination, WNS-HealthHelp speeds up approval times dramatically. This allows clinical staff to focus on complex cases, improving both the speed and quality of care decisions which is critical as CMS moves toward more stringent turnaround expectations.
   
2. Affordable: WNS-HealthHelp provides tailored code sets and clinical logic specifically for Medicaid that can reduce administrative waste and ensure relevance in this market. We also perform ongoing reviews of all Medicaid covered codes in an effort to make ordering more concise and reduce services that require prior authorization as needed.  This Medicaid health plan-specific design translates into lower operational costs and higher ROI which is particularly valuable as Medicaid budgets face increased scrutiny.
   
3. Flexible : We offer a spectrum of deployment options that range from fully delegated UM programs to modular clinical support to help Medicaid health plans scale with precision. This flexibility supports evolving health plan strategies, such as hybrid insourcing or phased modernization which can be an attractive option as many Medicaid health plans reassess in-house capabilities.
   
4. Standardized / Compliance Ready:  WNS-HealthHelp offers electronic submission standardization through FHIR, EMP, Portal and API interfaces.  Our AI tools align with CMS’s vision of reducing unnecessary prior authorizations and improving real-time decision-making. This means WNS-HealthHelp not only meets today’s rules—but is already prepared for the future.
   
5. Evidence-Based and Provider-Aligned: All clinical decisions are made by expert medical professionals and proven guidelines that combine published best practices with input from thousands of specialists in the Medicaid market.  We offer full transparency and a coordination with providers offering the specialist-to-specialist discussions on any clinical denial. This enhances accuracy, fosters provider trust, and supports improved quality ratings.

Real Results. Real Flexibility. Real Partnership.

With decades of experience supporting health plans across all lines of business—including complex Medicaid populations—WNS-HealthHelp offers more than just UM. We deliver a clinical operating system built to improve access, reduce harm, and control cost.

• Faster approvals with AI + clinician oversight
• Lower costs through Medicaid-optimized program design
• Improved satisfaction through real-time, transparent communications
• Flexible service models to match every payer structure

Real Results. Real Flexibility. Real Partnership.

As Medicaid enters a new era of reform and innovation, health plans are looking for  clinical partners who can evolve with them. With a configurable, intelligent, and affordable UM platform, WNS-HealthHelp is already ahead of the curve, helping plans lower costs, improve outcomes, and enhance member experiences—without compromise.

Let’s evolve Medicaid UM—together.

Contact HealthHelp to learn how we can support your Medicaid strategy.