Prior authorization reform: It’s time to measure progress, not just make commitments
Matt Patton, MD
Chief Medical Officer, Carelon Medical Benefits Management
Prior authorization reform will not be judged by what the industry says. It will be judged by whether people can see and feel a difference.
In 2025, more than 50 health plans, including many of our customers, voluntarily joined an industry commitment led by America’s Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association (BCBSA) to simplify and modernize prior authorization. As a medical benefits management partner, we help health plans turn commitments like these into operational progress.
Prior authorization has value when it is used selectively and supported by clear clinical standards. What matters now is not just what the industry has promised, but what those who rely on the process can see changing in practice.
Why progress matters now
For years, the conversation focused on what the industry should do to make prior authorization more timely, transparent, and better integrated with care delivery. That conversation is no longer enough.
The question now is whether providers, patients, and health plans can see measurable progress in how reform is actually taking shape, because they are not looking for more promises. They want to know that prior authorization is becoming more predictable, more efficient, and easier to navigate.
AHIP commitments point to where prior authorization needs to go
The AHIP commitments matter because they reflect a shared industry direction: greater standardization, clearer communication, expanded real-time responses, and a more connected prior authorization experience.
That direction is important not simply for setting expectations, but because it raises the bar for the progress that should be seen.
The next phase is execution
We entered this phase with a clear view of what execution would require. In many areas, we already had the underlying work underway. Over the past year, that work has accelerated in ways that align with AHIP’s broader commitment areas.
Some of the clearest signs of progress are already visible. Today, 95% of prior authorization requests come through our online provider portal for electronic prior authorization submission, and 80% are closed in real time. That scale matters because prior authorization reform will not be delivered through commitments alone. It will be delivered through the systems, workflows, clinical standards, and partnerships health plans rely on every day. Our review timeframes have also been shortened, and our reporting has been enhanced to support a faster, more transparent prior authorization experience. These are not abstract milestones. They are signs that prior authorization is becoming more digital, timely, and predictable for providers and health plans alike.
Standardization and workflow integration are where reform becomes real
Some of the most meaningful progress happens before a prior authorization decision is ever made.
We have been engaged in AHIP-led efforts to advance clinical documentation standardization, helping to bring greater clarity and consistency to case submissions. The goal is straightforward: make it easier to understand what information is needed up front, improve first-pass quality, and reduce unnecessary follow-up.
Of course, that kind of standardization does not change medical necessity criteria or remove the need for clinical review. But it does reduce avoidable variation and make the process more transparent for everyone involved.
The next step is making prior authorization work more organically within provider workflows. That is why we are advancing a FHIR-based Prior Authorization API aligned with Da Vinci Implementation Guidelines, a common framework for exchanging prior authorization information electronically. We are targeting a rollout during Q4 2026. The aim is to reduce duplicate efforts, support more seamless workflow integration, and make prior authorization feel less detached from care delivery itself.
Interoperability is the foundation
Expanding interoperability and data sharing is about more than infrastructure. It is part of building the foundation for a prior authorization experience supported by better-connected, more accessible information across the healthcare ecosystem.
Without that foundation, many of the industry’s broader goals around transparency, timeliness, and workflow integration become harder to achieve. With it, prior authorization can become more responsive to the realities of care delivery instead of remaining disconnected from them.
For health plans, that means stronger readiness for broader prior authorization modernization. For providers, it supports a more streamlined and usable experience. For the industry, it creates a clearer path from commitment to execution.
Progress must be visible
Commitments matter because they set direction. In healthcare, though, accountability depends on what can be demonstrated over time.
That is why measurable progress matters so much. It shows where momentum is building, where work remains, and whether prior authorization reform is taking shape in practice, not just in principle.
Prior authorization modernization is not about removing safeguards. It is about making them work better with greater clarity, stronger interoperability, and a more streamlined experience for the people who rely on them.
The industry has made commitments. People need to see and feel the progress. Carelon helps health plans make it operational.
Related reading:
Prior Authorization Progress Report – Tracking our progress in supporting health plans’ AHIP prior authorization commitments.