Reducing services requiring prior authorization 

Many Blue Cross and Blue Shield (BCBS) companies have reduced the scope of services subject to prior authorization in the past several years. 

We built upon that progress with targeted reductions, tailored to local markets. These actions focus on services with higher clinical risk or variation in practice and where prior authorization adds administrative burden without improving patient outcomes.

Across the individual market, Medicare Advantage and fully insured markets, these collective changes will result in approximately 11% fewer prior authorizations in 2026 — about 6.5 million fewer prior authorizations for patients — including a 15% reduction in Medicare Advantage.

To support these reductions, BCBS companies conducted comprehensive, data-driven reviews to eliminate many procedure codes in high-value services like imaging, cardiology, otolaryngology (ENT), radiology and other routine services. We also expanded provider performance-based approaches, like gold carding, to further improve the process for providers and expedite care for patients.

Here's how BCBS companies are leading the way:

Highmark Blue Cross Blue Shield

High-performing providers are seeing an 85% reduction in administrative work through a program from Highmark Blue Cross Blue Shield (Highmark BCBS). When clinicians with a proven track record of consistently meeting high clinical standards for specified service types that qualify for expedited review, they can become what Highmark BCBS calls a trusted provider for that service. Instead of the traditional prior authorization process, the 25,000 clinicians with this designation simply submit a very short pre-notification that includes the procedure and diagnosis codes. For members, this means fewer delays and less waiting for PA decisions.

“The pre-notification process is quick and easy, allowing us to schedule and perform necessary imaging procedures much more efficiently,” said the chief medical officer of an ambulatory practice in Buffalo, New York.

Each month, Highmark BCBS processes 40,000 expedited requests through this pathway. Of the more than 25,000 clinicians qualifying for faster review for at least one service type, about half are approved for multiple services. In addition to the dramatic reduction in paperwork, clinicians spend less time on peer-to-peer reviews.

Blue Cross Blue Shield of Minnesota

Patients battling complex conditions get to a faster “yes” for care, thanks to an effort from Blue Cross Blue Shield of Minnesota (Blue Cross MN) to improve the prior authorization process. In 2025, the health insurance provider focused on expanding its performance-based prior authorization program, which recognizes providers who consistently meet evidence-based standards for qualifying services.

Teams from Blue Cross MN invested in technologies to improve the scalability of the program and expand the model across orthopedic surgeries and advanced imaging services.

This targeted “greenlighting” approach has been especially successful with specialty practices, such as oncology and orthopedics, where a large share of providers meets program requirements. Blue Cross MN provides regular, transparent feedback and reduces oversight as providers demonstrate sustained success, working toward minimal or no routine audits.

Predictable approvals reduce administrative back-and-forth, allowing providers to act quickly and helping members access appropriate care without delay.

Independence Blue Cross

Independence Blue Cross has expanded its partnership with Penn Medicine to include additional high-performing health systems in a program designed to eliminate prior authorization requirements for certain outpatient imaging tests, including CT, PET, nuclear medicine scans, MRI and echocardiograms. Providers with a history of ordering imaging tests consistent with evidence-based guidelines are eligible for this program, resulting in 45,000 fewer prior authorizations a year from one health system alone.

Other positive results include faster decisions, with 83% of outpatient radiology requests approved in one-tenth of the time, and a 9% decrease in low-value requests for tests with no clinical benefit or where potential harm outweighs the benefit.

Anthem Blue Cross and Blue Shield

Anthem Blue Cross and Blue Shield (Anthem BCBS) has removed prior authorization requirements for several hundred services over the last few years. Where prior authorization applies, digital technologies have made it significantly faster and more efficient.

Care providers that adopt electronic prior authorization through Anthem BCBS provider portals and select electronic medical records benefit from two-way communication with clinicians at Anthem BCBS Plans, as well as quicker clinical determinations. And care providers can access all authorization data in a single location and quickly check the status of any authorization, even if it was not initially submitted electronically.

See how other BCBS companies are streamlining prior authorization for better patient outcomes.