Patients and providers have often complained about medical care delays and administrative burdens due to prior authorization requirements—the process insurers use to help control the costs of care and ensure patients receive clinically appropriate treatments. Insurers say they are finally ready to do something about it.
AHIP, a national trade association representing the health insurance industry, announced Monday that close to 50 health insurance plans have signed a commitment to streamline, simplify, and reduce prior authorization to connect patients more quickly to the care they need while administrative burdens on providers.
“The health care system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike. Health plans are making voluntary commitments to deliver a more seamless patient experience and enable providers to focus on patient care, while also helping to modernize the system,” said AHIP President and CEO Mike Tuffin in the announcement.
These actions will be implemented across insurance markets, including commercial coverage, Medicare Advantage, and Medicaid managed care consistent with state and deferral regulations, AHIP said. These commitments will benefit 257 million Americans.
Medicare Advantage plans have been accused of sometimes delaying or denying members access to services via prior authorization even when the requests met Medicare coverage rules. And providers complain that the paperwork associated with prior authorization is burdensome and has sometimes led to serious adverse events for their patients.
AHIP said that insurers will take actions to reform prior authorization so patients will receive faster, more direct access to appropriate treatments and medical services, and providers will benefit from streamlined workflows for a more efficient and transparent process.
“These measurable commitments—addressing improvements like timeliness, scope and streamlining—mark a meaningful step forward in our work together to create a better system of health,” said Kim Keck, president and CEO, Blue Cross Blue Shield Association, in the announcement. “This is an important foundation to address bigger problems together, at a time when technology and interoperability can deliver real improvements to patient experience.”
The participating health plans, which include several BlueCross BlueShield plans, Cigna, Humana, and UnitedHealthcare, agree to:
Standardize electronic prior authorization
They will work toward implementing common, transparent submissions for electronic prior authorization. This will mean developing standardized data and submission requirements (using FHIR® APIs) that support seamless, streamlined processes and faster turn-around times. AHIP said the goal is for the new framework to be operational and available to plans and providers by January 1, 2027
Reduce the scope of claims subject to prior authorization
Individual plans agree to reduce medical prior authorization as appropriate for the local market each plan serves, with demonstrated reductions by January 1, 2026.
Ensure continuity of care when patients change plans
Beginning January 1, 2026, when a patient changes insurance companies during a course of treatment, the new plan will honor existing prior authorizations for benefit-equivalent in-network services as part of a 90-day transition period. This action is designed to help patients avoid delays and maintain continuity of care during insurance transitions.
Enhance communication and transparency on determinations
Health plans will provide clear, easy-to-understand explanations of prior authorization determinations, including support for appeals and guidance on next steps. These changes will be operational for fully insured and commercial coverage by January 1, 2026, with a focus on supporting regulatory changes for expansion to additional coverage types.
Expand real-time responses
In 2027, at least 80 percent of electronic prior authorization approvals (with all needed clinical documentation) will be answered in real-time. This commitment includes adoption of FHIR® APIs across all markets to further accelerate real-time responses.
Ensure medical review of non-approved requests
Participating health plans affirm that all non-approved requests based on clinical reasons will continue to be reviewed by medical professionals—a standard already in place. This commitment is in effect now.
The voluntary commitment was welcomed by Department of Health and Human Services Secretary Robert F. Kennedy Jr. and Centers for Medicare & Medicaid Services Administrator Dr. Mehmet Oz after a roundtable discussion with several of the participating insurers. Americans shouldn’t have to negotiate with their insurer to get the care they need,” Kennedy said in an announcement.
“These commitments represent a step in the right direction toward restoring trust, easing burdens on providers, and helping patients receive timely, evidence-based care,” Dr. Oz said in the announcement. “We applaud these voluntary actions by the private sector, which is how these types of issues should be solved. CMS will be evaluating progress and driving accountability toward our shared goals, as we continue to champion solutions that put patients first.”