(June 26, 2025) - On Monday, some of the nation’s largest insurers officially pledged to make various actions to address problems caused by prior authorization. The announcement, shared in coordination with leadership from Centers for Medicare & Medicaid Services and the Department of Health and Human Services, identifies six areas of reforms that aim to enhance transparency with prior authorization decisions.
The reforms will apply to patients covered by Medicare Advantage, Medicaid managed care plans, Marketplace plans and commercial plans from companies that were represented as part of this handshake agreement which include Aetna, Inc., Blue Cross Blue Shield Association, Centene Corporation, The Cigna Group, Elevance Health, Humana, Inc. and UnitedHealthcare. The insurers have pledged to:
- Standardize electronic prior authorization submissions using Fast Healthcare Interoperability Resources (FHIR®)-based application programming interfaces.
- Reduce the volume of medical services subject to prior authorization by Jan. 1, 2026.
Honor existing authorizations during patient insurance transitions to ensure continuity of care.
- Enhance transparency and communication around authorization decisions and appeals including by providing clear explanations of the decision and support for appeals and guidance on next steps.
- Expand real-time responses to minimize delays in care with real-time approvals for most requests by 2027.
- Ensure medical professionals review all clinical denials.
It is important to note that CMS cannot enforce violations of these items as it is a voluntary pledge. CMS stated that they reserve the right to pursue additional regulatory actions if necessary.
U.S. Senator Roger Marshall was the sole senator invited to participate, underscoring his prominent role in shaping prior authorization reform. We appreciate Senator Marshall’s leadership and continued advocacy on behalf of Kansas hospitals, clinicians and the patients they serve.