Health plans to standardize prior auth processes

WASHINGTON – Leading health plans will adopt a standardized approach for providers submitting electronic prior authorization requests for the majority of medical services, which they say will accelerate patient access to care and reduce administrative burdens for providers.

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.

“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.

This action reflects the continued progress in advancing the industry’s voluntary, multi-year commitments made in partnership with the Department of Health and Human Services (DHHS) and the Centers for Medicare and Medicaid Services (CMS) 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.

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 Jan. 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 & 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

 Additional information on the industry’s voluntary commitments is available from AHIP and BCBSA.

Related: Dems introduce bill to eliminate prior auths for MA plans