Moving Prior Authorization into the 21st Century

Moving Prior Authorization into the 21st Century

By CMS Administrator Dr. Mehmet Oz

A common practice imposed by health insurers on patients and providers is their intrepid need to second-guess clinician treatment decisions by requiring prior authorizations before paying a claim. The current prior authorization process creates unnecessary delays for patients, burdens health care providers with excessive paperwork, and erodes trust between payers and health care providers, even though all share the same goal: delivering high-quality patient care.

When a health care provider orders a test, procedure or medication, the paper-based prior authorization process can drag on for days or even weeks. Clinicians and their staff waste hours filling out paper forms on clipboards, faxing them to insurers, and waiting around for phone calls. Completing prior authorizations costs health care providers $20-50 per hour and takes an average of 13 hours per week. On average, that's nearly $34,000 and 700 hours a year per health care provider that could otherwise be spent caring for patients.

It is way past time to axe the fax, kill the clipboard, and put patients over paperwork.

Last year, the U.S. Department of Health and Human Services and the Centers for Medicare & Medicaid Services (CMS) announced a landmark pledge with major health plans from across the country to streamline and improve the prior authorization process across the entire health care industry. This pledge reflects a shared commitment to modernizing prior authorizations to create a more responsive, patient-centered experience.

Since then, the health care industry has already begun delivering results. For example, leading health plans announced in April that they eliminated 11% of prior authorizations across a range of medical services, representing 6.5 million fewer prior authorizations for patients. Other plans are rapidly scaling standardized processes and reducing requirements, demonstrating that meaningful change is not only possible-it's happening. For example, one large national plan is eliminating authorization requirements for 30% of healthcare services and has committed to removing an additional 30% of remaining requirements by the end of 2026.

CMS is proud to announce the next chapter of that commitment: adding electronic prior authorization to the Health Tech Ecosystem . The initial landmark pledge effort brought the nation's major health plans to the table. This new initiative brings everyone else. Health systems, hospitals, physician practices, electronic health record (EHR) vendors, and digital health developers are now joining payers as a unified coalition aligned around a single mission: making electronic prior authorization work end-to-end, on time, for every patient.

Committed working groups across these stakeholders will align on CMS Interoperability and Prior Authorization Final Rule deadlines, addressing workflow gaps and technical handoffs that no single sector can fix alone. Prior authorization touches every part of the health care system; now, every part has a seat at the table.

CMS has also been working with EHR vendors to streamline and digitize the prior authorization process for medical items and services. As of January 1, 2026, impacted payers across Medicare Advantage, Medicaid & Children's Health Insurance Program (CHIP) and Marketplace (Federally-facilitated Exchange) plans are required to send prior authorization decisions for medical items and services within 72 hours for expedited (urgent) requests and 7 calendar days for standard (non-urgent) requests.

Electronic prior authorization interfaces from these payers will go live on January 1, 2027, and their use will eventually be incorporated into the Medicare Promoting Interoperability Program for hospitals and the Merit-based Incentive Payment System (MIPS) for clinicians. These policies will reduce burden on patients, health care providers, and payers, saving approximately $15 billion over 10 years.

CMS is also building on these efforts by proposing major reforms to expand electronic prior authorization to drugs.

This transformation extends well beyond any single agency or payer. Modernizing prior authorization is a catalyst for a broader realignment of the health tech ecosystem, bringing together EHR vendors, health plans, clearinghouses, pharmacy benefit managers, and digital health developers around a common set of standards: National Council for Prescription Drug Programs (NCPDP) for pharmacy benefit drugs and Fast HealthCare Interoperability Resources (FHIR®) Standards for medical items and services.

CMS has engaged extensively with the health tech community, working with vendors to embed electronic prior authorization directly into EHRs, and with health IT developers to ensure that implementation guides reflect real-world workflows. This ecosystem-wide coordination is what separates this effort from previous attempts at prior authorization reform. When data flows seamlessly -- between a provider's EHR, the payer's electronic prior authorization interfaces, and a patient's health record -- the entire system becomes more responsive, more accountable, and more focused on what matters most: getting patients the care they need without unnecessary delays or burdens.

If you're a health care provider, you can visit our Electronic Prior Authorization webpage to learn more and get started.

CMS is committed to reducing administrative burden on health care providers, strengthening patients' access to care, and promoting interoperability across the health care ecosystem and will continue to pursue innovative solutions to achieve those goals.

View a video message from me and a timeline highlighting the progress CMS is making on improving prior authorization.

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