Health plans adopt standardized approach to prior authorization
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Health plans adopt standardized approach to prior authorization The approach will be used for medical services that are commonly subject to prior authorization, such as orthopedic surgeries and imaging services.
Reimbursement By Susan Morse , Executive Editor | April 24, 2026 | 11:20 AM Photo: FS Productions/Getty Images Health plans have announced a new initiative to adopt a standardized approach for electronic prior authorization requests, according to AHIP.The standardized approach will be used for medical services that are commonly subject to prior authorization, such as orthopedic surgeries and imaging services, including CT scans and MRIs.Insurers signing on include UnitedHealthcare Cigna, CVS Health Aetna, Elevance Health, Humana, Centene and numerous Blue Cross plans nationwide.
Geisinger Health Plan and Kaiser Permanente are also part of the initiative that begins on January 1, 2027. The standardized approach applies to commercial coverage, Medicare Advantage and Medicaid managed care. Additional services will be added over time, according to AHIP. The standards do not impact individual plans’ clinical policies or coverage determinations.WHY THIS MATTERSThe policy will speed patient access to care and reduce administrative burden for providers. It will also maintain safeguards to ensure care is safe, effective and affordable, according to AHIP.Incomplete or incorrect submission of documentation and information as part of prior authorization requests often cause delays with determinations, requiring providers to resubmit correct details before the request can be reconsidered.The industry is engaging with organizations representing providers and technology partners to share and receive feedback on the data requirements, with a goal of supporting the widest possible adoption beginning in 2027.Participating health plans will continue adopting these standards on a rolling basis as the standardization commitment is implemented next year. This is a voluntary initiative by participating health plans.THE LARGER TRENDThis action reflects the progress in advancing the industry’s voluntary, multi‑year commitments, made in partnership with the Department of Health and Human Services and the Centers for Medicare and Medicaid Services, in June 2025 to streamline and simplify prior authorization. The industry recently reported an 11% reduction in prior authorization volume as part of this initiative, according to AHIP.Payers have come under congressional scrutiny for prior authorization denials and delays. Last year, House members rolled out a bipartisan bill that would task board-certified specialists with determining the medical need of prior authorization requests.
The Reducing Medically Unnecessary Delays in Care Act proposed to reform the practice of prior authorization in Medicare and Medicare Advantage by requiring that board-certified physicians in the same specialty make prior authorization decisions.ON THE RECORD“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,” said Mike Tuffin, AHIP President and CEO."Standardization is another important milestone as we continue to make meaningful progress on improving the prior authorization process. To deliver a truly streamlined experience, our partnership with providers is critical,” said Kim Keck, president & CEO of Blue Cross Blue Shield Association. “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.” Topic: Accounting & Financial Management, Operations, Patient Engagement, Reimbursement