More transparency, clearer communication

Health care is complicated enough, and patients want simple and straightforward information.

We’re providing that by simplifying our communications about prior authorization (PA), sharing updates in clear, consumer-friendly language, and offering actionable guidance on how to appeal the decision.

Plan actions include:

• Strengthening customer service and training staff on clear writing to enhance member support and navigation
• Improving the format of communications by summarizing key information upfront
• Enhancing member portals and platforms for easy access to medical policy and appeals information
• Providing dashboards with up-to-date prior authorization status

Here's how Blue Cross and Blue Shield companies are leading the way:

Blue Cross Blue Shield of Massachusetts

Teams at Blue Cross Blue Shield of Massachusetts (BCBSMA) worked hard to reduce the number of services requiring PA, but even after reductions, there were still the same level of calls from providers, asking to confirm if a procedure needed PA.

To address this, BCBSMA launched a Prior Authorization Quick Look Up tool in April 2025. Through BCBSMA’s public website, providers can quicky check if a service requires PA and the status of a patient’s request. Providers have seamless access as the site does not require registration or login.

Data shows the efforts to improve communications are growing in popularity. Providers used the tool 7,300 times in its first month. By January 2026, there were nearly 150,000 uses.

Blue Cross Blue Shield of Puerto Rico

GuideWell is a not-for-profit, mission-driven, policyholder-owned health services organization with a portfolio of companies that include Florida Blue, the Blue Cross Blue Shield plan in Florida, and Triple-S Salud, Puerto Rico’s Blue Cross Blue Shield plan. At Triple-S Salud BCBS, nearly 70 nurses completed training in intentional listening and empathetic communication to better support members during prior authorization (PA) outreach calls to communicate determinations and explain next steps.

The initial focus was on durable medical equipment (DME), such as bath chairs and hospital beds — services that CMS and private issuers identify as having elevated fraud risk and that are less likely to be authorized than other services.

The training helped instill an empathy-first approach for all members requiring PA for medical services. Every communication —– whether oral or written, in English or Spanish —– begins by clearly explaining to a member what was requested, the reason for the decision, and the steps taken to try to secure approval, such as provider outreach for additional clinical information. As one nurse notes, “While we can’t always change the outcome of a review, we can transform the member’s experience.”

A key takeaway for members is that the conversation doesn’t end with a “no.”

Nurses guide members through alternatives, including other covered services, referrals to care management or connections to community and social support resources.

Discover how BCBS companies are improving the prior authorization process.