Rethinking SLAs in member communications: speed and automation

In healthcare communications, Service Level Agreements (SLAs) are the guardrails that ensure critical information reaches members on time. They set the time limits for health plans to respond to utilization management (UM) requests.

They help decide how fast plans make claims decisions. They also help resolve complaints. Additionally, they provide important materials for members, such as ID cards and provider directories.

Across all these, timelines are only getting tighter. While UM is often under the brightest spotlight, strict CMS or ERISA rules govern every type of member communication.

Missing even one deadline can result in compliance penalties or audit findings. Understanding that meeting deadlines helps build and keep member trust, not just following rules, is important. Members expect timely, accurate communications, and regulators require proof that organizations consistently meet standards.

The challenge?

Most health plans are still relying on fragmented, manual processes that leave too much room for error. Every handoff, every proof, every translation request eats into the clock.

Even if the team makes the clinical decision on time, they can still experience delays. These delays may happen when preparing, printing, or mailing the member notice. Such delays can lead to the plan not being compliant.

This is why automation is no longer optional; it’s essential. Automation speeds up every part of the workflow. This includes compliance checks, pre-press proofs, and USPS dispatch.

It creates the efficiency and accuracy that health plans need. This helps them meet the deadlines set by the Centers for Medicare & Medicaid Services (CMS). And with the right partner, plans can transform SLAs from a compliance risk into a competitive advantage.

The current SLA landscape

In recent years, CMS has gradually shortened SLA windows for many areas. This includes prior authorizations, claims notices, and grievance resolutions.

UM has experienced major changes. Soon, providers must get prior authorizations within 72 hours for urgent cases. For non-urgent cases, they have seven days.

Yet the stress continues beyond that. You must handle complaints within seven days. Claims adjudication notices often have only 72 hours for urgent decisions. Appeals also have strict timelines for auto-forwarding.

Beyond decisions and notices, CMS also holds plans accountable for the timely delivery of member-facing materials. We must make and send out ID cards quickly after enrollment. Provider directories must be accurate and updated regularly. These requirements ensure members have what they need to access care immediately and choose in-network providers with confidence.

Health plans are feeling the squeeze. Manual processes, separate teams, and old vendor handoffs can easily delay a letter. This can lead to compliance penalties, unhappy members, and audit issues.

What do CMS timelines profoundly say?

Discussing “tight SLAs” is easy, but what do they actually require? CMS rules set exceptionally specific turnaround times, and each stage of the workflow matters:

• Decision timeframes (Utilization Management): Starting January 2026, health plans must follow the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). They must process urgent prior authorization requests within 72 hours. Staff must process non-urgent requests within seven calendar days. This marks a major acceleration from previous standards and places new pressure on UM teams.
• Claims adjudication notices: For claims under ERISA, you must send notices within 72 hours for urgent claims. For pre-service claims, you must send them in 15 days. For post-service claims, you must send them in 30 days. These requirements ensure that members quickly receive information about coverage decisions that directly affect their care and costs.
• Complaints and grievances: CMS needs outreach within seven days for non-urgent complaints using the Complaints Tracking Module (CTM). Prompt follow-up is essential both for compliance and for maintaining member trust.
• CMS emphasizes the rules for handling appeals quickly. If needed, someone must send these appeals to the Independent Review Entity (IRE) automatically. While these processes vary by case, we clearly expect that people will not tolerate delays.
• ID cards: Plans must issue and mail new member ID cards within seven business days of enrollment (CMS marketing guidelines). Delays can directly affect a member’s ability to access care or fill prescriptions.
• Provider directories: CMS requires plans to keep provider directories up to date. You must update them every 30 days. This helps members find in-network providers easily. Outdated or inaccurate directories have been a common CMS audit finding.

These rules create a compressed timeline that doesn’t stop at the decision itself. Once a determination is made, plans must:

1. Prepare and approve the content.
2. Complete translations and alternate formats (Braille, large print, non-English).
3. Send the final files to a vendor for printing and mailing.

In practice, the SLA clock starts when someone finalizes a letter for release. Every step after that must align to ensure delivery within CMS deadlines. Even a small delay in routing, proofing, or mailing can push a plan out of compliance.

Breaking down the SLA timeline

Here’s what a typical urgent SLA cycle looks like from approval to delivery:

Each segment leaves little room for error. Even a small delay—like a stalled proof approval or a missed print cut-off—can cascade into non-compliance.

The bottlenecks and risks

The SLA journey is only as strong as its weakest link. Even if a clinician makes a timely decision or claim, delays can still occur.

Delays can happen when making the UM letter. They can also occur with the claim notice, grievance response, appeal communication, ID card, or provider directory update.

Such delays can cause a plan to be out of compliance. Common roadblocks include:

• Internal reviews take too long. Manual routing between compliance, legal, and member services teams can add hours or even days to the process. Without automated workflows or SLA “flags,” a letter can sit in someone’s inbox. Meanwhile, the compliance clock keeps running.
• Translation and alternate formats: CMS requires that member communications be available in different languages and formats. This includes Braille, large print, and audio. Producing these versions on a compressed timeline can be challenging. Delays in securing accurate translations or properly formatted files can create last-minute bottlenecks that jeopardize delivery deadlines.
• Vendor delays in proofing or printing can happen. When vendors use manual pre-press processes, proof turnaround may take longer than expected. A missed same-day proof approval can mean losing a whole business day in production. Most plans do not have that time under current SLA windows.
• Mailing cut-offs and USPS transit times: Even after someone approves and prints a letter, timing remains critical. Missing a daily USPS dispatch cut-off can delay mailing by 24 hours, putting compliance at risk. Add in variability in postal transit times, and health plans have little room for error.

The consequences of these bottlenecks are serious:

• Regulatory penalties and fines if CMS find late or incomplete communications.
• Corrective action plans (CAPs) that add administrative burden and further slow operations.
• Audit findings that damage reputations and consume valuable resources.
• Erosion of member trust happens when there are delays in important communications. This includes things like prior authorization or claims decisions. These delays can feel like barriers to care.

In short, every inefficiency compound risk. Without automation and proactive controls, health plans scramble to patch delays instead of confidently meeting SLA obligations.

The role of automation in meeting tight SLAs

For many health plans, managing SLAs has often been a reactive scramble. They chase approvals, coordinate translations, and rush to meet print deadlines. Automation changes that equation entirely, shifting SLA compliance from a high-risk, manual effort to a predictable, proactive process.

Leading health plans are implementing automation in several key areas:

• Pre-built templates that meet compliance requirements: You don’t have to start from scratch every time. Automated platforms provide standard templates that match CMS model documents. You can quickly populate variable fields with plan-specific data, which eliminates rework and reduces the risk of errors.
• Integrated data feeds: Automated systems can pull member details, preferences, and regulatory metadata directly from eligibility, claims, or CRM systems. This ensures that letters are not only accurate but also immediately aligned with translation and alternate-format requirements.
• Automated workflows: Automation advances to the next step immediately after completing the previous one. This replaces manual routing of proofs and approvals. Content can move smoothly from compliance review to pre-press proof to the print queue. This happens without delays or extra steps.
• Real-time tracking and reporting: The system automatically records each timestamp. This includes letter approval, proof return, and USPS dispatch. This creates a complete audit trail for CMS readiness. It also gives operations teams the chance to step in before an SLA breach happens.

The results are obvious. Approvals happen more quickly. Translations go straight into templates.

They reduce production cycles from days to hours. Health plans can focus on providing better member experiences. They can do this while knowing that they will meet SLA deadlines.

Automation also makes other important tasks easier. For example, it connects ID card production to enrollment feeds. It also uses data integrations to keep provider directories accurate every 30 days. This happens without adding extra work.

Equally important, automation future-proofs compliance. By building a flexible foundation that adjusts as CMS deadlines get shorter, health plans can maintain accuracy and efficiency. This helps them stay ready for audits without overwhelming their teams. It turns SLAs from a compliance risk into a competitive edge.

Final thoughts

The pressure to meet CMS SLAs isn’t slowing down — it’s accelerating. Manual processes and outdated workflows leave too much at risk. Now is the time to modernize.

By changing how they manage SLAs with automation and strong vendor partnerships, health plans can lower compliance risks. This will help them build member trust and prepare for future regulatory changes.

Toppan Merrill is here to help you look at your current SLA processes. We can help you create a smarter, faster, and stronger communications workflow.

How Toppan Merrill can help

At Toppan Merrill, we specialize in the complexities of healthcare SLAs. Our solutions are built to help health plans deliver:

• Proven SLA compliance with CMS and ERISA timelines.
• Fast, accurate services across all formats and channels.
• Scalable automation tools that streamline pre-press, proofs, and approvals.
• Real-time compliance monitoring through our Control Center platform.
• Secure, audit-ready communications to stand up to CMS review.

We have helped top plans improve SLA performance. We do this by using automation, improving vendor handoffs, and creating workflows. These workflows anticipate regulatory deadlines instead of just reacting to them.

Contact us today to learn more.