HEALTH PLANS TAKE NEXT STEP TO STREAMLINE AND SIMPLIFY PRIOR AUTHORIZATION FOR PATIENTS AND PROVIDERS

The following information was released by the America's Health Insurance Plans (AHIP):

by AHIP

WASHINGTON, DC Leading health plans today announced a new initiative to accelerate patient access to care and reduce administrative burdens for providers while maintaining safeguards to ensure care is safe, effective and affordable. Participating plans are adopting a standardized approach for providers submitting electronic prior authorization requests for the majority of medical services.

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. These services span commercial coverage, Medicare Advantage and Medicaid managed care. Additional services will be added over time. The standards do not impact individual plans' clinical policies or coverage determinations.

This action reflects the continued progress in advancing the industry's voluntary, multi-year commitments made in partnership with HHS and CMS in June 2025 to streamline and simplify prior authorization. The industry recently reported an 11 percent reduction in prior authorization volume as part of this initiative.

Prior authorization is an important safeguard that helps ensure care is safe, effective, evidence-based and as affordable as possible. 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.

"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 and 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."

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 beginning January 1, 2027. The initial list of health plans voluntarily participating in the standardization initiative includes:

American Specialty Health

AmeriHealth Caritas

Arkansas Blue Cross and Blue Shield

Blue Cross of Idaho

Blue Cross Blue Shield of Alabama

Blue Cross Blue Shield of Arizona

Blue Cross and Blue Shield of Hawaii

Blue Cross and Blue Shield of Kansas

Blue Cross and Blue Shield of Kansas City

Blue Cross and Blue Shield of Louisiana

Blue Cross Blue Shield of Massachusetts

Blue Cross Blue Shield of Michigan

Blue Cross and Blue Shield of Minnesota

Blue Cross and Blue Shield of Nebraska

Blue Cross and Blue Shield of North Carolina

Blue Cross Blue Shield of North Dakota

Blue Cross and Blue Shield of Rhode Island

Blue Cross Blue Shield of South Carolina

BlueCross BlueShield of Tennessee

Blue Cross Blue Shield of Wyoming

Blue Shield of California

Capital Blue Cross

CareFirst BlueCross BlueShield

CareSource

Centene

The Cigna Group

CVS Health Aetna

Elevance Health

Evry Health

Excellus Blue Cross Blue Shield

Geisinger Health Plan

GuideWell Mutual Holding Corporation (Florida Blue and Triple-S)

Health Care Service Corporation

Highmark Inc.

Horizon Blue Cross Blue Shield of New Jersey

Humana

Independence Blue Cross

Kaiser Permanente

L.A. Care Health Plan

Medical Mutual of Ohio

Molina Healthcare

Neighborhood Health Plan of Rhode Island

Oscar Health

Premera Blue Cross

Regence BlueShield, Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah, Asuris Northwest Health, BridgeSpan Health

SCAN Health Plan

Sentara Health Plans

UnitedHealthcare

Wellmark Blue Cross and Blue Shield