CMS takes next step to improve prior authorizations

WASHINGTON – The Centers for Medicare & Medicaid Services has added electronic prior authorization to its Health Tech Ecosystem. The agency says health systems, hospitals, physician practices, electronic health record (EHR) vendors and digital health developers are now joining payers as a unified coalition aligned around improving electronic prior authorization.

Working groups have been formed, vendors work to streamline process

• Committed working groups across these stakeholders will align on Interoperability and Prior Authorization Final Rule deadlines, addressing workflow gaps and technical handoffs.
• The agency has also been working with EHR vendors to streamline and digitize the prior authorization process for medical items and services. As of Jan. 1, 2026, impacted payers across Medicare Advantage, CHIP and Marketplace plans are required to send prior authorization decisions for medical items and services within 72 hours for expedited requests and seven calendar days for standard requests. Electronic prior authorization interfaces from these payers will go live Jan. 1, 2027.

Commentary from CMS Administrator Dr. Mehmet Oz

“CMS has engaged extensively with the health tech community, working with vendors to embed electronic prior authorization directly into EHRs, and with health IT developers to ensure that implementation guides reflect real-world workflows. This ecosystem-wide coordination is what separates this effort from previous attempts at prior authorization reform. When data flows seamlessly -- between a provider’s EHR, the payer’s electronic prior authorization interfaces, and a patient’s health record -- the entire system becomes more responsive, more accountable, and more focused on what matters most: getting patients the care they need without unnecessary delays or burdens.”

Early results on reduced prior authorizations

Last year, the U.S. Department of Health and Human Services and CMS announced a pledge with major health plans from across the country to streamline and improve the prior authorization process across the entire health care industry.

Since then, CMS says, the health care industry has already begun delivering results. For example:

• Leading health plans announced in April that they eliminated 11% of prior authorizations across a range of medical services, representing 6.5 million fewer prior authorizations for patients.
• One large national plan is eliminating authorization requirements for 30% of health care services and has committed to reviewing and removing additional requirements.

Additional information

• Health care providers can visit CMS’s Electronic Prior Authorization webpage to learn more and get started.
• View a video message from Oz and a timeline highlighting CMS’s progress in improving prior authorization.