Major Health Plans Pledge to Simplify Prior Authorizations Using FHIR Standards

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According to AHIP, the U.S. healthcare system is plagued by outdated, manual processes that create significant burdens for both patients and providers. In response, participating health plans agreed on six specific actions to streamline the prior authorization process. A key commitment is the standardization of electronic prior authorization. This involves developing standardized data and submission requirements using FHIR Application Programming Interfaces (APIs), expected to be available by January 1, 2027. This aims to significantly improve efficiency. Furthermore, plans committed to demonstrating reductions in medical prior authorizations by January 1, 2026. They also agreed that when a patient switches insurance companies, the new plan must honor existing prior authorizations during a 90-day transition period. Additionally, they aim for at least 80% of electronic approvals to be answered in real-time by 2027, and non-approved requests will undergo professional review based on clinical reasons. These changes apply across commercial coverage, Medicare Advantage, and Medicaid managed care, benefiting an estimated 257 million Americans. This collective effort aims to ensure that patients receive timely, medically necessary care while reducing administrative burdens throughout the system.