06/01/2026

Prior Authorization Reforms

Many providers struggle with submitting, processing, and obtaining prior authorizations from various payors. To describe the issue of prior authorizations as vexing is a gross understatement. The following is a summary of current reform efforts. 

First, payors have made voluntary commitments to reform these requests. In June 2025 approximately 50 payors, including commercial insurers, Medicare Advantage Plans, and managed Medicaid plans, covering a combined total of 257 enrollees agreed to voluntarily simplify and reduce requirements to obtain prior authorizations. A survey by AHIP and the Blue Cross Blue Shield Association in April 2026 shows that these voluntary efforts have resulted in elimination of 11% of requirements that amount to 6.5 million fewer requests. The decrease in requests to Medicare Advantage Plans amounts to about 15%.

Payors have also voluntarily developed and implemented policies they provide for 90 days of continuity of care. They honor existing approvals for equivalent benefits in-network if patients switch plans mid-treatment.

Additional voluntary efforts will begin in 2027 when payors have voluntarily committed to standardizing submissions of requests for prior authorization electronically. Payors have also committed to processing at least 80% of electronic submissions in real time. Imaging and orthopedic surgeries will be prime targets of these efforts.

In addition to these voluntary efforts, the Centers for Medicare and Medicaid Services (CMS) continues to mandate changes with regard to prior authorization. As of March 31, 2026, for example, payors are required to post data regarding prior authorizations covering information from 2025. Specifically, they are required to provide data about approval and denial rates, and outcomes of appeals for denials that involve medical items and services. CMS also requires plans to provide decisions on standard requests for prior authorizations within 7 calendar days. Urgent requests must be processed within 72 hours this year. By January 1, 2027, CMS will require payors to develop and implement certain capabilities regarding patient access, provider access, payor-to-payor record transfers and electronic prior authorization submissions and responses.

With regard to requests for prior authorization related to drugs, CMS issued a proposed rule in April 2026, that, if finalized, will require Medicaid, CHIP, and ACA plans to support 3 pharmacy   standards related to pharmaceuticals by October 2027. Providers will be able to obtain formulary information, check coverages in real time and electronically submit requests for drugs. ACA plans will be required to respond to standard drug-related requests within 72 hours and expedited requests within 24 hours. The proposed rule will also expand requirements for public reports. Expanded requirements will include requiring payors, for example, to provide specific reasons for denials of requests for drugs. 

On May 14, 2026, CMS announced the establishment of an Electronic Prior Authorization Acceleration initiative to address key challenges and develop solutions ahead of deadlines in 2027 described above. Thus far, 29 healthcare organizations of various types have signed on to this Initiative. 

True reform is sorely needed. It can’t come soon enough!

©2026 Elizabeth E. Hogue, Esq. All rights reserved.
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