Payers promise standardized electronic prior auths

Healthcare payers are serious about prior authorization reform, with leading health plans now promising to adopt a standardized electronic request process for most medical services.

America's Health Insurance Plans (AHIP) announced on Friday that major payers have committed to an initiative to reduce the administrative burden of prior authorizations, while accelerating patient access to care. The initiative will apply to services commonly subject to prior authorizations, such as orthopedic surgeries and imaging, including CT scans and MRIs.

Health plans signing on to the standardized electronic request process span commercial coverage, Medicare Advantage and Medicaid managed care, including industry heavy hitters The Cigna Group, UnitedHealthcare, Humana, CVS Health Aetna and various Blues plans.

"As more providers adopt electronic prior authorization, this standardized approach will mean faster answers for patients, a more consistent experience for providers and less friction for everyone," Mike Tuffin, AHIP president and CEO, said in the announcement.

The participants said they will adopt the standards on a rolling basis starting on Jan. 1, 2027. But the commitment could apply to medical services representing more than 70% of prior authorization volume by the end of the year, Cigna reported.

"We want patients to get the care they need when they need it, and we want doctors and their teams to be able to focus on patients -- not paperwork,” said Amy Flaster, M.D., chief medical officer at The Cigna Group. "We are leading much-needed improvements to make prior authorization clearer and more consistent. While this is important progress, we know there's more to do as we continue our journey to deliver a simpler, more personalized health care experience to all those we serve."

UnitedHealthcare also said in its own announcement that it "will be working aggressively to add more services" under the standard electronic process, with similar promises coming from other major payers. UnitedHealthcare also announced last week that it is eliminating prior authorizations for rural providers.

But these industry giants and other health plans have already made strides with prior authorization reform. AHIP reported earlier this month that a similar group of health plans had eliminated 11% of prior authorizations across a range of medical services as part of a pledge to streamline and simplify the process.

Over 50 payers signed the multi-year pledge last year, in partnership with HHS and CMS. They agreed to six commitments: reducing the scope of claims subject to prior authorizations, ensuring continuity of care when patients change plans, enhancing communication and transparency on determinations, expanding real-time responses, ensuring medical review of non-approved requests and standardizing an electronic process.

Health plans will focus on the latter commitment in the coming year to hit "another important milestone," Kim Keck, president and CEO of Blue Cross Blue Shield Association, said in the announcement.

However, the success of adopting a standardized prior authorization request process will hinge on provider collaboration with payers, Keck stated.

"Looking ahead to 2027, we anticipate continued collaboration with health systems and CMS to ensure we collectively embrace approaches that move at the speed of care to create a better system of health," she said.

Participating payers will also partner with technology companies to share and receive feedback on data requirements to achieve robust adoption of the electronic standards in 2027.

CMS recently made effective a standardized electronic prior authorization process for Medicare Advantage, Medicaid, CHIP and plans sold through the Affordable Care Act's Marketplace.

Starting in January 2026, these plans have had to implement application programming interfaces (APIs) using the Fast Healthcare Interoperability Resources, or FHIR, standard to streamline the process. The APIs must allow providers to determine whether an item or service requires prior authorization, identify specific documentation requirements, submit the request and receive decisions directly in the EHR or practice management system.

Incomplete or incorrect documentation is a major reason determinations get delayed, AHIP stated. A standardized electronic process for prior authorization requests can address this obstacle while speeding up the process for payers and providers.

 Jacqueline LaPointe is a graduate of Brandeis University and King's College London. She has been writing about healthcare finance and revenue cycle management since 2016.