Fixing Prior Authorization: What the New CMS and HHS Pledge Means

On June 23, 2025, CMS and HHS brought together executives from the nation’s largest health insurers to sign a voluntary pledge to fix the broken prior authorization process. These companies collectively insure more than 80% of Americans. The pledge responds to growing pressure from providers, patients, and policymakers to reduce delays, increase transparency, and ease the administrative burden of accessing care.

Prior authorization has long been a pain point. It’s consistently cited by clinicians and patients as a cause of unnecessary delays, denied treatments, and rising operational costs. While this isn’t the first attempt to address the issue, this pledge is more specific, includes clearer deadlines, and has garnered broad industry support. It may not be perfect, but it’s a meaningful step if organizations follow through.

What’s Changing

The pledge includes six core commitments, each targeting a critical flaw in today’s prior authorization process:

1. Standardized e-PA using FHIR APIs
   Participating health plans will implement electronic prior authorization systems using Fast Healthcare Interoperability Resources (FHIR) to enable automated, interoperable requests and responses.

2. Streamlining Prior Authorization Requirements
   By early 2026, payers are expected to reduce the number of services that require prior authorization, thereby eliminating unnecessary approvals and reducing friction in the care delivery process.

3. 90-Day Continuity of Care
   When patients change plans, their existing authorizations will remain valid for 90 days to prevent disruption in ongoing treatment.

4. Clear Denial Explanations and Appeals Guidance
   Denials must include specific reasons and clear, actionable appeal instructions to minimize confusion and reduce administrative back-and-forth.

5. Real-Time Approval for Routine Requests
   By 2027, standard prior authorization requests should be processed in real-time or near real-time to eliminate delays for routine care.

6. Clinical Review for All Denials
   Only licensed clinicians will be allowed to issue denials. This ensures medical decisions are informed by professional judgment, not just administrative rules.

How This Is Different

These aren’t entirely new ideas, but this time there is more weight behind them:

• Clear deadlines for implementation in 2026 and 2027

• Broad industry participation from major payers

• CMS and HHS oversight and public progress tracking

• Alignment with federal rules already in development

This is the most substantial national effort so far to replace outdated, manual systems with modern tools that support timely care.

What Needs to Happen Next

Signing the pledge is just the start. Success depends on execution:

• Modernize IT Infrastructure: Update systems to support FHIR-based workflows across payer and provider environments. Technologies like Google Cloud Healthcare API, Microsoft Azure Health Data Services, and AWS HealthLake can support these efforts.

• Automate Manual Processes: Eliminate faxes, phone calls, and PDFs by replacing them with structured, automated workflows. Solutions from partners like Redox can help connect systems and automatically trigger authorizations.

• Redesign Workflows: Make authorization status and decisions visible to all relevant staff. Using platforms like Salesforce Health Cloud or Microsoft Dynamics 365, organizations can integrate prior authorization data into care management workflows.

• Ensure Clinical Oversight: Utilize licensed clinical reviewers for decisions related to patient care. AI-based support tools, such as those from Myndshft or Mesh Health, can help ensure the correct information is available to reviewers at the point of decision.

• Track Metrics: Measure time to decision, approval and denial rates, and overall impact on care delivery. Business intelligence tools such as Snowflake, Power BI, or Tableau can help surface insights and ensure accountability.

Organizations that wait until late 2026 will be behind. Getting started now is key.

How Productive Edge Can Help

Productive Edge helps healthcare payers and providers move from pledge to action. We bring technical and domain expertise to modernize workflows, integrate systems, and reduce delays:

• Assess Workflows: Identify pain points and improvement opportunities.

• Integrate FHIR APIs: Build secure, standards-based connections across systems.

• Automate Decisions: Streamline approvals for high-volume, routine cases.

• Improve Visibility: Provide real-time insights into status and outcomes.

• Support Adoption: Train teams and manage change across departments.

• Track Performance: Build reports aligned to CMS expectations and internal goals.

Why It Matters

This is more than a compliance exercise. It’s an opportunity to improve care delivery, reduce admin costs, and strengthen payer-provider relationships. Organizations that act now will be ready for what comes next.

If you're ready to move forward, we can help. Let’s start the conversation.