WASHINGTON, DC – Health insurance plans today announced a series of commitments to streamline, simplify and reduce prior authorization – a critical tool to ensure their members’ care is safe, effective, evidence-based and affordable. Building on health plans’ existing efforts, these new actions are focused on connecting patients more quickly to the care they need while minimizing administrative burdens on providers.
For patients, these commitments will result in faster, more direct access to appropriate treatments and medical services with fewer challenges navigating the health system.
For providers, these commitments will streamline prior authorization workflows, allowing for a more efficient and transparent process overall, while ensuring evidence-based care for their patients.
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Participating health plans commit to:
- Standardizing Electronic Prior Authorization. Participating health plans will work toward implementing common, transparent submissions for electronic prior authorization. This commitment includes the development of standardized data and submission requirements (using FHIR® APIs) that will support seamless, streamlined processes and faster turn-around times. The goal is for the new framework to be operational and available to plans and providers by January 1, 2027.
- Reducing the Scope of Claims Subject to Prior Authorization. Individual plans will commit to specific reductions to medical prior authorization as appropriate for the local market each plan serves, with demonstrated reductions by January 1, 2026.
- Ensuring 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.
- Enhancing 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.
- Expanding 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.
- Ensuring 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.
These commitments are being made by health plans offering fully insured and self-insured commercial coverage, Marketplace plans, Medicare Advantage, and Medicaid managed care, consistent with state and federal regulations.
Progress will be tracked and reported. A full list of participating health plans and additional information are available at: www.ahip.org/supportingpatients and XXXXX.