aceAI-enabled automation of prior authorization in managed care pharmacy
Source article: A pharmacist-overseen, artificial intelligence-enabled model for provider-side prior authorization: From burden to opportunity (PAVE-1)
Abstract: Prior authorization (PA) imposes substantial administrative burdens on clinicians, contributing to burnout, delayed care, and excess health care spending. Artificial intelligence (AI) is emerging as a tool to automate PA tasks in managed care pharmacy, yet concerns persist regarding transparency, bias, and overreliance on autonomous systems. This is particularly true in payer-deployed AI systems that may deny claims without adequate clinical review. This viewpoint proposes a pharmacist-overseen, AI-enabled syste…
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Published September 1, 2026 in Journal of Managed Care & Specialty Pharmacy, this viewpoint proposes a pharmacist-overseen, AI-enabled prior authorization model for provider organizations and health systems. It outlines a conceptual workflow where AI automates routine data extraction and submissions and routes complex cases to pharmacists for clinical verification.
The proposal matters because prior authorization affects clinician workload, care delays, and spending, and AI adoption in this area raises transparency and bias concerns. The article does not report measured outcomes from deployment; benefits are framed as potential and contingent on collaboration among payers, PBMs, providers, and vendors and on future research.
- Article is a viewpoint proposing a provider-side model, not an empirical trial of an implemented system.
- Conceptual workflow has AI handling routine data extraction and submissions and routing complex cases to pharmacists for verification against guidelines and payer criteria.
- Authors frame model as aligning with Centers for Medicare & Medicaid Services interoperability mandates and requiring collaboration among payers, pharmacy benefit managers, providers, and vendors.
A pharmacist-overseen AI system for provider organizations could reduce prescriber workload and increase first-pass approval rates by automating routine data extraction and submissions while routing complex cases to pharmacists.
Use of AI to automate prior authorization raises concerns about transparency, bias, and overreliance, with payer-deployed systems potentially denying claims without adequate clinical review.
The rundown
Prior authorization is described as imposing substantial administrative burdens contributing to burnout, delayed care, and excess spending. The viewpoint contrasts payer-deployed AI that may deny claims without adequate clinical review with a provider-side alternative.
The proposed model integrates pharmacists across design, triage logic, clinical review, and continuous improvement. AI handles routine extraction and submission; pharmacists verify appropriateness against guidelines and payer criteria for complex cases.
Viewpoint is conceptual and untested; benefits are presented as potential and authors note need for further research and collaborative implementation.
Sources
- Peer-reviewedJournal of Managed Care & Specialty Pharmacy2026-09-01
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