itiliti Health
Itiliti Health automates prior authorization workflows for U.S. health plans and state Medicaid agencies through a FHIR-based, policy-as-code platform built around HL7 Da Vinci CRD, DTR, and PAS standards, targeting CMS-0057 compliance ahead of the January 2027 federal deadline.
- Company typePrivate
- Founded2018
- HeadquartersEden Prairie, United States
- Headcount51–100
- GTM typeB2B
- OfferingSoftware
What itiliti Health does
Itiliti Health is a healthcare technology company that automates prior authorization workflows for U.S. health plans and state Medicaid agencies. The company sells a modular, open-API platform built on HL7 FHIR interoperability standards (specifically the Da Vinci CRD, DTR, and PAS implementation guides) that enables payers to digitize medical policies, determine in real time whether prior authorization is required, route requests to appropriate utilization management or delegated vendor systems, and auto-approve requests that meet defined clinical criteria. The platform comprises five modules — PA Checkpoint™, Policy Management, Prior Authorization Routing, Auto Auth, and Clinical Assistant — all sharing a structured policy-as-code data model designed to eliminate the ambiguity of AI-interpreting narrative policy documents. The company was incubated inside Blue Cross and Blue Shield of Minnesota after founder and CEO Michael Lunzer identified prior authorization inefficiencies during an Entrepreneur-in-Residence tenure, giving the product domain credibility and a flagship reference customer.
Itiliti Health generates revenue through subscription-based licensing of its platform to enterprise and mid-market health plans and state Medicaid agencies, with multi-year contracts sold through direct field sales and a consultative demo-driven motion. Pricing is not publicly disclosed; the platform is sold either as an integrated suite or as individual modules. The company maintains a broad partner ecosystem spanning delegated clinical criteria vendors (InterQual, MCG), HIE networks (eHealth Exchange, Availity), EHR and FHIR server providers (Oracle, InterSystems, 1upHealth, Onyx Health), and consulting/implementation firms (Deloitte, Tegria, CitiusTech), positioning Itiliti as an orchestration layer rather than a replacement for existing payer or provider systems. The company markets HIPAA-certified, SOC 2 and HITRUST-aligned compliance and advertises a 90-day implementation timeline.
The company's strategic positioning is anchored to the CMS-0057-F January 2027 federal mandate requiring payers to implement electronic prior authorization, and to industry adoption of HL7 Da Vinci standards. Named customers include BCBSMN (incubator), a large regional Blues plan that achieved first-in-nation CMS-0057 compliance at scale, Cox HealthPlans, PrimeWest Health, and South Country Health Alliance. The company is headquartered in Eden Prairie, Minnesota, employs 51-100 people, and has raised approximately $5.5M in cumulative funding across seed and incremental rounds since 2021, with investors including Altitude Ventures, Bread and Butter Ventures, Groove Capital, M25, and SpringTime Ventures.
itiliti Health firmographics
Firmographics- Name
- itiliti Health
- Legal name
- Itiliti Health, Inc.
- Website
- https://itilitihealth.com
- Company type
- Private
- Founded year
- 2018
- Operating status
- Operating
- Headcount range
- 51–100 employees
- Short description
- Itiliti Health automates prior authorization workflows for U.S. health plans and state Medicaid agencies through a FHIR-based, policy-as-code platform built around HL7 Da Vinci CRD, DTR, and PAS standards, targeting CMS-0057 compliance ahead of the January 2027 federal deadline.
- Ownership category
- akta.pro rank
itiliti Health industry classification
Industry- Product category
- Healthcare Payer Prior Authorization Software
- NAICS
- Computer Systems Design and Related Services (54151)
- SIC
- Services-Prepackaged Software (7372)
- akta.pro primary industry
- Prior Authorization (ePA), Utilization Management & Coverage Verification (HLACAKAE)
- akta.pro secondary industries
- Payer-Provider Data Exchange (X12, prior auth, claims/clinical attachment) (HLACABAK), Interoperability Standards, Profiles & Implementation (HL7/FHIR/IHE) (HLACABAA), Prior Authorization & Utilization Management (HLACACAC)
Keywords
Where itiliti Health is headquartered
LocationHeadquarters
- HQ city
- Eden Prairie
- HQ country
- United States
- HQ region
- North America
Offices2 records
Markets served
itiliti Health business model
Business model- GTM type
- B2B
- Offering type
- Software
- Cost components
- Personnel, Technology or R&D, Marketing or Sales, Infrastructure, Operations
Revenue model
- Healthcare Payer SaaS Platform: Itiliti Health generates revenue through subscription-based licensing of its prior authorization automation platform to health plans and state Medicaid agencies. The platform's modular architecture allows payers to license individual components or the full suite, with contracts structured as multi-year agreements typical of enterprise healthcare SaaS.
Pricing tiers
| Model | Billing | Price |
|---|---|---|
| Subscription | Multi-year contract | Modular platform sold as integrated suite or individual components |
Go-to-market motion2 records
Distribution channels2 records
Marketing channels6 records
itiliti Health product offering
Product offeringCore offering
Itiliti Health sells a modular, FHIR-based prior authorization automation platform for U.S. health plans and state Medicaid agencies. The suite includes PA Checkpoint™ (CRD/Is Auth Required and policy transparency), Policy Management, Prior Authorization Routing, Auto Auth (deterministic automated approvals), and Clinical Assistant (AI-assisted review), all designed to deliver CMS-0057-F compliant, touchless prior authorization and reduce administrative cost.
Product overview
Itiliti Health offers a modular, open-API prior authorization automation platform built around its flagship PA Checkpoint™ product. The suite consists of five integrated modules: PA Checkpoint™ serves as the central orchestration hub providing CRD-based 'Is Auth Required?' determination and policy transparency; Policy Management provides authoring and governance tools for digitizing and structuring payer medical policies; Prior Authorization Routing intelligently directs requests to appropriate internal systems or delegated vendors; Auto Auth delivers deterministic automated approvals grounded in governed policy criteria; and Clinical Assistant provides AI-assisted review support within policy-defined guardrails. All modules share a common structured policy data model and FHIR-based interoperability layer, supporting CMS-0057-F compliance through CRD, DTR, and PAS transactions.
Differentiator
Problem solved
Functional benefit
Products and services
- PA Checkpoint™
Quantifiable outcome
- $5 million per year in administrative cost savings for customers
- +6 more outcomes
Companies that use itiliti Health
Customer profileNamed customers5 records
Segments2 records
Ideal customer profiles2 records
itiliti Health technology and API
TechnologyTechnology focussed Yes
API detail
- Has API
- Yes
- API docs
- API detail
Core technology
AI maturity
App detail
Integration3 records
AI capability7 records
Feature8 records
itiliti Health partnerships and signals
Strategic signalPartnerships
21 partnerships are on record, tiered core and minor.
- Concord TechnologiescoreStrategic partnership to integrate Concord's AI-powered Concord Connect document processing platform with Itiliti Health's prior authorization automation engine. The combined solution enables payers to convert unstructured clinical documents (PDFs, faxes, scanned attachments) into actionable structured data for automated prior authorization decision-making. The integration supports CMS-0057-F regulatory compliance and reduces manual processing burden for health plans.
- South Country Health Alliance (SCHA)coreSouth Country Health Alliance, a county-based purchasing health plan serving Minnesota, selected Itiliti Health's PA Checkpoint to streamline prior authorization transparency and reduce administrative burden for providers while achieving regulatory compliance.
- PrimeWest HealthcorePrimeWest Health partnered with Itiliti Health to implement its CMS-compliant PA Checkpoint platform, aiming to modernize prior authorization processes and enhance real-time digital policy transparency for providers. The partnership aligns with CMS regulations ahead of the 2026/2027 compliance deadline.
- Long GameminorConsulting partner listed on the Itiliti Health Partners page.
- Point of Care PartnersminorConsulting partner listed on the Itiliti Health Partners page.
- TegriaminorConsulting partner listed on the Itiliti Health Partners page.
- ExcellHCAminorConsulting partner listed on the Itiliti Health Partners page.
- MRIoAminorConsulting partner listed on the Itiliti Health Partners page.
- ImpresivminorConsulting partner listed on the Itiliti Health Partners page.
- ZSminorConsulting partner listed on the Itiliti Health Partners page.
- DeloitteminorConsulting partner listed on the Itiliti Health Partners page.
- Toney HealthcareminorConsulting partner listed on the Itiliti Health Partners page.
- ClearCoreminorConsulting partner listed on the Itiliti Health Partners page.
- CitiusTechminorConsulting partner listed on the Itiliti Health Partners page.
- WEDIcoreWEDI (Workgroup for Electronic Data Interchange) is an association partner. Itiliti Health is a Platinum Sponsor of the WEDI National Conference 2026 and regularly partners with WEDI to host educational webinars on CMS-0057 implementation and prior authorization modernization. WEDI is recognized in HIPAA legislation as an advisor to the Secretary of HHS.
- HL7 Da Vinci ProjectcoreAssociation partner. The HL7 Da Vinci Project develops the interoperability standards (CRD, DTR, PAS) that underpin Itiliti Health's platform. The company actively participates in Da Vinci Community Roundtables and implements Da Vinci Implementation Guides.
- TAHP (Texas Association of Health Plans)minorAssociation partner. Itiliti Health sponsors and speaks at the TAHP Texas Covered Health Care Conference + Expo.
- CAHPminorAssociation partner listed on the Itiliti Health Partners page.
- SOC 2minorAssociation partner representing SOC 2 compliance certification.
- HiTrustminorAssociation partner representing healthcare cybersecurity and compliance certification (HITRUST).
- Blue Cross Blue Shield AssociationcoreBlue Cross Blue Shield Association representatives (Dr. Razia Hashmi) co-present with Itiliti Health at the Da Vinci Community Roundtable on 'Building Reusable, Scalable Prior Authorization Tools: A Case Study in Policy Digitization and HL7 Da Vinci DTR Implementation.'
Scale indicators9 records
Recent moves6 records
Expansion highlights5 records
itiliti Health competitors and assessment
Company assessmentBroad incumbents
- Availity: Availity is a large payer-provider data exchange and clearinghouse platform that also serves prior authorization workflows. It is both a listed technology partner and a competitive incumbent that could bundle PA orchestration into its existing payer contracts, making it a relevant direct competitor and channel partner for Itiliti Health.
- Waystar: Waystar is a large revenue cycle management platform serving hospitals and health systems with adjacent prior authorization functionality. It overlaps with Itiliti Health on PA workflow automation but addresses the provider side of the equation rather than payers as primary customers.
- Surescripts: Surescripts operates the nation's largest health information network, including electronic prior authorization capabilities. It competes broadly with Itiliti Health in the PA and prescription interoperability space and benefits from incumbency in payer and provider connectivity.
- Change Healthcare (Optum): Change Healthcare, now part of Optum/UnitedHealth Group, offers InterQual clinical decision support and broader revenue cycle and utilization management solutions. It is a broad incumbent that competes with Itiliti Health on delegated clinical criteria and PA workflow orchestration while also serving as a potential acquirer or partner given its market scale.
Emerging players
- Anterior: Anterior is an emerging AI-native prior authorization automation company targeting health plans. It overlaps with Itiliti Health's PA Checkpoint offering but takes an LLM-driven approach to clinical note interpretation, positioning itself as a next-generation alternative to policy-as-code architectures.
- Elligint Health: Elligint Health focuses on value-based care and utilization management analytics for payers, with overlap into prior authorization workflow intelligence. Listed as a technology partner of Itiliti Health, it represents an adjacent competitor in payer UM optimization.
Direct peers
- Cohere Health: Cohere Health is a direct competitor offering AI-driven prior authorization and utilization management automation for health plans. Like Itiliti Health, Cohere targets payer-provider interoperability and PA workflow digitization, though it leans more heavily on AI interpretation of clinical documentation versus Itiliti's structured policy-as-code approach.
- Edifecs: Edifecs provides healthcare data interoperability and prior authorization solutions for payers and providers, including CMS-0057 compliance tooling. It competes directly with Itiliti Health on FHIR-based PA orchestration and payer-provider data exchange.
- Myndshft: Myndshft provides prior authorization automation and eligibility verification software to health plans and providers. It is a direct peer competing for similar payer accounts with comparable FHIR-based PA workflow automation capabilities.
Others
- MCG Health: MCG provides evidence-based clinical decision support and care guidelines used by payers in utilization management. Itiliti Health's platform integrates with MCG as a delegated clinical criteria vendor, making MCG a partner but also an adjacent competitor if it expands into workflow orchestration.
Market position
Strengths5 records
Weaknesses5 records
Competitive moat5 records
Key risks6 records
Key highlights7 records
Customer concentration
itiliti Health social profiles
Digital presenceitiliti Health financial estimates
Financial estimateRevenue estimate
Valuation estimate
itiliti Health leadership team
Management profileNumber of profiles
Profiles15 records
itiliti Health funding detail
Funding detailFunding overview
Funding rounds5 records
Investors6 records
Funding detail is available on the Subscription and Enterprise plan.Contact sales →
itiliti Health M&A and investment
M&A and investmentM&A
Investments
M&A and investment is available on the Subscription and Enterprise plan.Contact sales →
Frequently asked questions about itiliti Health
What does itiliti Health do?
Itiliti Health sells a modular, FHIR-based prior authorization automation platform for U.S. health plans and state Medicaid agencies. The suite includes PA Checkpoint™ (CRD/Is Auth Required and policy transparency), Policy Management, Prior Authorization Routing, Auto Auth (deterministic automated approvals), and Clinical Assistant (AI-assisted review), all designed to deliver CMS-0057-F compliant, touchless prior authorization and reduce administrative cost.
Is itiliti Health a public or private company?
itiliti Health is a private company. It is classified as venture growth investor backed and is currently operating.
When was itiliti Health founded?
itiliti Health was founded in 2018. It employs 51 to 100 people.
Where is itiliti Health based?
itiliti Health is headquartered in Eden Prairie, United States, in the North America region.
How does itiliti Health make money?
One revenue line is on record: healthcare Payer SaaS Platform.
Who are itiliti Health's main competitors?
Broad incumbents on record are Availity, Waystar, Surescripts and Change Healthcare (Optum). Emerging players are Anterior and Elligint Health. Direct peers are Cohere Health, Edifecs and Myndshft. MCG Health is listed as an others.
Does itiliti Health have an API?
Yes. Itiliti Health offers a flexible, open-API framework that enables prior authorization automation for health plans. The platform supports FHIR-based electronic prior authorization APIs for CRD (Coverage Requirements Discovery), DTR (Documentation Templates and Rules), and PAS (Prior Authorization Support) transactions required under CMS-0057-F. APIs can be integrated with EMR/EHR platforms, enabling payers to receive prior authorization decisions within workflows. The platform acts as an orchestration layer routing requests to internal utilization management systems and/or delegated vendor systems (e.g., delegated clinical criteria vendors). Inputs, outputs, and created artifacts are primarily FHIR resources, with customer-specific functionality beyond basic FHIR capabilities. FHIR server compatibility includes cloud-native FHIR functionality on AWS and Azure, as well as all major FHIR servers. A large regional Blues plan achieved full CMS-0057 compliance by integrating through API with EMR platforms. Developer documentation is at itilitihealth.com/solutions.
What industry is itiliti Health in?
itiliti Health's product category is Healthcare Payer Prior Authorization Software. Its primary akta.pro industry code is HLACAKAE, Prior Authorization (ePA), Utilization Management & Coverage Verification, with a secondary code of HLACABAK, Payer-Provider Data Exchange (X12, prior auth, claims/clinical attachment). Its NAICS code is 54151 and its SIC code is 7372.