How's It Going With Prior Auth?

Health insurers pledged in June 2025 to overhaul their processes as part of a Trump administration initiative to reduce the volume of prior authorization requirements and modernize how requests are handled. According to AHIP (Association of Health Insurance Plans), they pledged to the following goals for January 1, 2026

• Reducing the Scope of Claims Subject to Prior Authorization. Individual plans have committed to specific reductions to medical prior authorization as appropriate for the local market each plan serves.
• Ensuring Continuity of Care When Patients Change Plans. When a patient changes insurance companies during a course of treatment, the new plan honors 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 should provide clear, easy-to-understand explanations of prior authorization determinations, including support for appeals and guidance on next steps.
• 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 allegedly already in place. (This commitment was in effect at the time of the announcement.)

Many insurers set January 1, 2026, as the target for measurable reductions, but how far have they come? While carriers say they are making progress, provider groups such as the American Medical Association contend that little has changed for patients and clinicians on the ground.

Prior authorization — or prior approval — requires clinicians to secure insurer signoff before performing procedures, prescribing certain medications, or ordering tests. Plans say it helps control unnecessary or low-value care. The AMA says it helps promote substandard care.

Providers argue that approvals can take hours or days, even for routine services, leading to delayed diagnoses or treatment. News reports of patients waiting for life-saving care, sometimes with tragic outcomes, have intensified scrutiny.

The June 2025 pledge aimed to blunt these concerns and respond to growing state and federal pressure to simplify the process. Again, most major insurers pledged to:

• Cut the number of medical services needing prior authorization, particularly common procedures like colonoscopies and cataract surgeries, by January 1, 2026.
• Honor existing prior authorizations for 90 days when a patient changes insurers mid-treatment.
• Offer clearer explanations for denials and ensure all denials receive a medical review.

I didn't believe it then, and I'm not sure I believe it now.

What the largest insurers are doing, according to US-RxCare and the relevant insurer webssites:

CVS/Aetna--As far as I can tell, they are the furthest along of any insurance company. Aetna is changing prior authorization (PA) rules by automating approvals, bundling requests (like meds with procedures for cancer), and using AI, while also removing some requirements (like for some cataract surgeries) to reduce provider burden and speed up care, though some rules remain. Specific changes vary by plan, with recent updates focusing on streamlining approvals for cancer regimens (MRIs, meds) and updating drug lists in early 2026. Members and providers must check their plan's Evidence of Coverage (EOC) or ID card for details. Key Changes include:

• Automation & AI: Aetna is allegedly automating approvals for many requests, making them almost instant, and integrating AI into tools like their health app. Hopefully, they are not using it to deny claims
• Bundling: They're combining related requests (e.g., scans, procedures, and medications for certain cancers) into one approval process.
• Targeted Relief: PAs have been rolled back for some services like video EEGs and home infusion for certain drugs, while requirements for others, like cataract surgeries, were removed in 2022.
• Focus on Oncology: Significant bundling efforts are in place for complex cancer care, involving Evolent for regimen reviews.
• Drug List Updates: Recent changes (January 2026) affect medical plan drug lists, with existing PAs honored until they expire, prompting discussions with doctors about alternatives. 

For Providers:

• Check for Updates: Use Aetna's provider portal or EDI for specific precertification lists and updates to find out the latest for plans in your area.
• Verify Member Plans: Rules differ, so always check the specific plan (Commercial, Medicare, etc.) and the member's EOC (Evidence of Coverage).

UnitedHealthcare — The company dropped prior authorization requirements for 231 procedures in early December 2025, including nuclear medicine studies, certain obstetrical ultrasounds, and electrocardiography procedures. It previously reduced approval requirements for services that consistently adhere to evidence-based guidelines. Providers should check the UHC provider portal for the latest requirements. 

Cigna — Cigna Healthcare in August announced removing nearly 25 percent of medical services from prior authorization (or precertification) requirements. With the removal of these additional 600 codes, the company has now eliminated prior authorization for more than 1,100 medical services since 2020, aiming to "simplify the health care experience" for both customers and clinicians.

Humana — The insurer says it eliminated about one-third of outpatient prior authorizations, including for colonoscopies and certain imaging studies. Humana is working to reduce the red tape on prior authorization in several important ways:

• Reducing prior authorization requirements – By January 1, 2026, Humana will eliminate approximately one-third of prior authorizations for outpatient services. Humana will remove the authorization requirement for diagnostic services across colonoscopies and transthoracic echocardiograms and select CT scans and MRIs.
• Faster, more streamlined process for approvals – By January 1, 2026, Humana will provide a decision within one business day on at least 95% of all complete electronic prior authorization requests, expediting care decisions and helping beneficiaries get the right care in a timely manner. Currently, Humana provides a decision within one business day on more than 85% of outpatient procedures. What happens with the other 15%?
• Creating a national gold card program for physicians – In 2026, Humana will launch a new gold card program that waives prior authorization requirements for certain items and services for providers who have a proven record of submitting coverage requests that meet medical criteria and delivering high-quality health care with consistent outcomes for Humana members. https://news.humana.com/press-room/press-releases/2025/humana-accelerates-efforts-to-eliminate-prior-authorization

Blue Cross Blue Shield plans — These efforts to commit to reducing in-network prior authorization for medical services as appropriate for the local market each plan serves, with demonstrated reductions by January 1, 2026. 

• Fast-tracking responses for electronic requests: Patients understandably want fast responses regarding prior authorization. In 2027, for all coverage types, BCBS companies commit to providing a near-real-time response for at least 80% of electronic prior authorization requests for medical services that include all necessary clinical documentation. Not that great, really.
• Providing more personalized support and more transparency: BCBS companies will work to ensure messages about prior authorization are clear and contain personalized information, including what is needed to support approval, next steps, and available appeal processes. They are enhancing transparency by providing trained support staff to answer questions about documentation and guidance on the process. 

State Policy Activity

States are rapidly enacting prior authorization reforms, focusing on "gold card" programs, stricter timelines (e.g., Vermont, Virginia), continuity of care (honoring old authorizations), AI use (Maryland), and requiring clinical peer reviews (Indiana, Tennessee). Key reforms include provider exemptions for high approval rates, electronic processes (Maryland, Washington), mandated review timelines, and requirements for patient-specific data for AI. 

Key Areas of Reform by State:

• Gold Card Programs: States like Arkansas, West Virginia, and Texas are expanding these, exempting providers with high approval rates from certain PA requests, sometimes extending to group practices.
• Decision Timelines: Vermont set 24-hour (urgent) / 2-day (non-urgent) rules, while Virginia requires 72-hour (expedited) / 1-week (standard) responses.
• Continuity of Care: Bills in states like Massachusetts require new insurers to honor prior authorizations for 90 days to a year for chronic conditions,
• Clinical Review & AI: Indiana requires physician-led clinical peer reviews for denials, and Maryland now mandates patient-specific data for AI-driven PA and requires reporting when AI contributes to denials, reports this MultiState article.
• Electronic Systems: Maryland and Washington are requiring insurers to use electronic prior authorization (ePA) systems, aligning with federal efforts.
• Prescription Specifics: Tennessee mandates specific clinical criteria for certain prescription drugs, 
• Eliminating Duplicative Requirements: Prior authorization, which forces physicians to obtain health plan approval before treating patients, has long been criticized for delaying care and creating avoidable administrative hurdles. In California, SB 306 directly addresses these issues by empowering regulators to waive prior authorization for services that are almost always approved and requiring health plans to publish data that shines a light on approval patterns.

Medicare Advantage

Medicare Advantage plans, starting January 1, will face stricter requirements:

• Standard Requests must be reviewed within 7 calendar days

• Expedited Requests must be completed within 72 hours

• Approved Authorizations Stay Valid for the entire course of treatment, even if your provider leaves the network or patients switch to another plan

• Public Reporting: Medicare Advantage plans must share data on how many prior authorization requests are approved, denied, or overturned on appeal

These rules build on changes beginning in 2025 and are meant to ensure patients don’t face unnecessary delays in care.

Commercial pledges, state reforms, coupled with new federal timelines for Medicare Advantage starting in 2026, signal that regulatory pressure is likely to intensify this year.