2026 will bring progress on simplifying prior authorization

Prior authorization is an important safeguard used by both public and private payers to help ensure patients receive care that is safe, evidence-based and as affordable as possible – ultimately ensuring that every health care dollar is spent wisely. This safeguard helps hold down out-of-pocket costs for patients and premiums for everyone.

While prior authorization is utilized very selectively, the prior authorization experience often reflects the fragmentation and outdated processes that hold back the performance of the health care system. This experience can be frustrating for all involved – particularly for patients.

Six months ago, AHIP, Blue Cross Blue Shield Association (BCBSA) and leading health plans joined leaders from HHS and CMS to announce a series of multi-year voluntary commitments to streamline and simplify prior authorization. Simplifying prior authorization means that patients will have faster, more direct access to appropriate treatments and medical services. When providers transition away from antiquated approaches, such as fax machines, these commitments will also enable a more efficient, transparent and modernized experience.

These commitments are being implemented across insurance markets and programs, including for people with fully insured commercial coverage, Medicare Advantage and Medicaid managed care consistent with state and federal regulations. Health plans serving nearly 270 million Americans are participating in this initiative.

2026 Commitments

Since the announcement of the initiative last June, health plans have been working to implement the first series of commitments which took effect January 1, 2026:

• Reducing the Scope of Claims Subject to Prior Authorization. Individual plans have committed to specific reductions to medical prior authorization as appropriate for the local market each plan serves.
• Ensuring Continuity of Care When Patients Change Plans. When a patient changes insurance companies during a course of treatment, the new plan is honoring existing prior authorizations for benefit-equivalent in-network services as part of a 90-day transition period. This action is designed to help patients avoid delays and maintain continuity of care during insurance transitions.
• Enhancing Communication and Transparency on Determinations. Health plans are providing clear, easy-to-understand explanations of prior authorization determinations, including support for appeals and guidance on next steps.
• Ensuring Medical Review of Non-Approved Requests. Participating health plans affirm that all non-approved requests based on clinical reasons will continue to be reviewed by medical professionals – a standard already in place. (This commitment was in effect at the time of the announcement.)

AHIP and BCBSA will provide the first of regular updates on the industry-wide implementation of these commitments this spring.

2027 Commitments

The initiative announced by health plans also includes two interrelated and transformational commitments that have multi-year timelines and require close collaboration among health plans and providers:

• Expanding Real-Time Responses. In 2027, at least 80 percent of electronic prior authorization approvals (with all needed clinical documentation) will be answered in real-time. This commitment includes adoption of FHIR^® APIs across all markets to further accelerate real-time responses.
• Standardizing Electronic Prior Authorization. Participating health plans will work toward implementing common, transparent submissions for electronic prior authorization. This commitment includes the development of standardized data and submission requirements (using FHIR^® APIs) that will support seamless, streamlined processes and faster turnaround times. The goal is for the new framework to be operational and available to plans and providers by January 1, 2027.

These two commitments are a substantial technical and operational undertaking that will ultimately enable most prior authorizations to be routinely approved at the point of care, while giving providers a faster and more consistent experience. AHIP and BCBSA will provide an update on this effort later this year.

For patients to experience the full benefits, providers will need to adopt these standards and transition to electronic prior authorization, rather than faxes or other manual formats. We recognize this transition will require meaningful change for many providers as nearly half of prior authorization requests are currently submitted by fax or phone.

Taken together, the full series of multi-year commitments are intended to help patients access care more quickly and help providers focus on patient care while reducing administrative burdens for patients, providers and plans alike. Health plans welcome continued collaboration with policymakers and stakeholders across the health care system as we work to fulfill these commitments.