Electronic Prior Authorization

We’re committed to working with health plans and EHR vendors to improve the prior authorization process with these goals in mind: 

• Reduce burden on you, your team, your patients, and your payers with a measurable reduction in non-digital workflows
• Patients experience faster, more predictable access to care and drugs when medically reasonable and appropriate
• Increase transparency and accountability
• Improve access to health information
• Advance interoperability across the health care system
• Build confidence in standards-based technology
   

Using payers’ Prior Authorization APIs to request prior authorization for medical items and services benefits health care providers through:

• Improved efficiency
  • Faster decisions through integrated electronic workflows connecting your EHR system to Prior Authorization APIs
  • Standardized, structured documentation formats with discrete data fields for easy electronic transmission of frequently requested prior authorization items, services, and drugs 
  • Real-time access to coverage and documentation requirements
  • Submit and track prior authorization requests without portals  
• Reduced burden, including time spent on paperwork
• Reduced duplicative testing
• Reduced reliance on manual, portal-based, and fax workflows
• Improved patient care, including:
  • Comprehensive patient information integrated into workflows for improved care coordination  
  • Faster approvals means providing safe, timely access to care for your patients
  • Improved communication with patients
  • Enhanced transparency
  • Patient empowerment through real-time access to their care data

Use payer-supported Prior Authorization APIs, so you can begin to experience the many benefits. 

Required implementation among certain health plans regulated by CMS starts January 1, 2027, but it’s important to be prepared in advance.

Take these steps now:

1. Talk to your EHR vendor to confirm readiness. Ask questions to help you understand their implementation roadmap, including:
   • What’s our implementation timeline?
   • What are our EHR system’s API integration and electronic prior authorization capabilities?
   • Is our current EHR certified to support the necessary functionality?
   • What specific features are you building for:
     • Payer Prior Authorization API integration?
     • Electronic prior authorization workflows?
     • Seamless data exchange?
   • Will we need to upgrade our system or purchase additional modules?
   • What testing opportunities will you provide?
   • What training and technical support will you offer?
   • Are you participating in pilot programs with payers?
2. Upgrade your technology, including EHR templates and workflows, if needed. Your vendor can give you information and support.

3. Start testing: We strongly encourage providers to take an active role in advancing electronic prior authorization by participating in Fast Healthcare Interoperability Resources® (FHIR) API testing with your EHR vendor and payer partners. Contact your EHR vendor to learn how and when you can begin testing to make sure your systems are ready for electronic prior authorization. Early testing and collaboration between your practice, EHR vendor, and payers is essential to ensure seamless, real-world implementation of electronic prior authorization workflows. Engage now to:

   • Identify gaps
   • Validate workflows
   • Build the technical readiness needed to meet upcoming implementation goals
   • Improve the experience for your patients and staff

   Testing Resources:

   • Office of the National Coordinator for Health Information Technology (ONC)-supported DaVinci Inferno test kits:
     • Coverage Requirements Discovery
     • Documentation Templates & Rules
     • Prior Authorization Support
   • HL7 FHIR: We work with HL7 International on FHIR standards
   • Workgroup for Electronic Data Interchange (WEDI): We work with this organization per a HIPAA statute
4. Prescription Drugs: Ask your EHR vendor if it supports electronic prior authorization for prescription drugs.

1. Work with your EHR vendor to enable the connection
2. Train staff on new workflows
3. Prepare to address patient questions about prior authorization decisions
4. Request prior authorizations electronically beginning January 1, 2027

At a June 2025 roundtable, HHS Secretary Robert F. Kennedy, Jr., CMS Administrator Dr. Mehmet Oz, and the National Coordinator for Health IT Information Technology Dr. Thomas Keane met with industry leaders to discuss their pledges to streamline the prior authorization process. Major health plans, provider organizations, and health IT stakeholders across the country joined this commitment — signaling a unified effort to drive meaningful change.

The current prior authorization process often creates unnecessary delays, places administrative burden on providers, and can stand between patients and the care they need. These challenges have contributed to frustration across the health care system and have eroded trust among patients, providers, and payers.

By coming together to address these issues, stakeholders are taking an important step toward restoring confidence in the health care system. Reducing friction, improving transparency, and streamlining workflows will enhance efficiency and help ensure that patients get timely, appropriate care.

Building trust requires accountability and collaboration. This pledge reflects a shared commitment to modernize prior authorization processes and create a more responsive, patient-centered health care experience.

Participating companies pledged to:

1. Standardize electronic prior authorization by using FHIR-based APIs
2. Reduce the volume of medical services subject to prior authorization 
3. Honor existing authorizations during insurance transitions to ensure continuity of care
4. Enhance transparency and communication around authorization decisions and appeals
5. Expand real-time approvals to minimize delays in care for most requests by 2027
6. Ensure medical professionals review all clinical denials

Learn more about the pledge and our goals here: HHS Secretary Kennedy, CMS Administrator Oz Secure Industry Pledge to Fix Broken Prior Authorization System

We’re committed to using other new health technologies. The Wasteful and Inappropriate Service Reduction (WISeR) Model aims to reduce wasteful and inappropriate Original Medicare spending. This model leverages enhanced technologies, such as artificial intelligence (AI) and machine learning (ML), combined with clinician review, to ensure select items and services are furnished in line with Medicare coverage criteria. It also incorporates electronic prior authorization. View more information on the WISeR model.

Regulations & Policies

• Interoperability & Prior Authorization final rule, effective April 8, 2024: See fact sheet, press release, slides, and FAQs
• 2026 CMS Interoperability Standards and Prior Authorization Proposed Rule
• Health Information Technology Standards & Implementation Specifications final rule, effective July 17, 2024
• Hospital Inpatient Prospective Payment System & Long-Term Care Hospital Prospective Payment System proposed rule, released April 10, 2026: See fact sheet and press release
• Interoperability Standards & Prior Authorization for Drugs proposed rule, released April 10, 2026: See fact sheet and press release

Testing

• Health Technology Ecosystem webpage
• HL7 FHIR webpage
• WEDI webpage

Pharmacy

• Proposal to Support National Council for Prescription Drug Programs Standards

Resources

• Health Systems & Providers: Connect to Networks & “Kill the Clipboard" webpage
• Medicare Promoting Interoperability Program webpage – for eligible hospitals and critical access hospitals
• Prior Authorization & Pre-Claim Review Initiatives webpage
• MIPS Promoting Interoperability Performance Category webpage for MIPS-eligible clinicians