Advocacy, Petitions, and Government Updates

Participating health insurers have pledged to:

• 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 turn-around times. The goal is for the new framework to be operational and available to plans and providers by January 1, 2027.

• Reducing the Scope of Claims Subject to Prior Authorization: Individual plans will commit to specific reductions to medical prior authorization as appropriate for the local market each plan serves, with demonstrated reductions by January 1, 2026.

• Ensuring Continuity of Care When Patients Change Plans: Beginning January 1, 2026, when a patient changes insurance companies during a course of treatment, the new plan will honor 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 will provide clear, easy-to-understand explanations of prior authorization determinations, including support for appeals and guidance on next steps. These changes will be operational for fully insured and commercial coverage by January 1, 2026, with a focus on supporting regulatory changes for expansion to additional coverage types.

• 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.

• 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 is in effect now.

Source: AHIP