On Monday, June 23, 2025, the Department of Health and Human Services hosted a roundtable at which dozens of health insurers, coordinated through AHIP and the Blue Cross Blue Shield Association, committed to a set of prior authorization reforms. The signatories include UnitedHealthcare, Aetna, Cigna, Humana, Elevance, Kaiser Permanente and most Blue Cross Blue Shield plans, and AHIP says the commitments cover plans serving about 257 million Americans across commercial, Medicare Advantage, Medicaid managed care and marketplace products. HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Mehmet Oz presented it as a voluntary agreement with deadlines and metrics.
Practice managers have heard this before. UnitedHealthcare and Cigna announced prior authorization reductions in 2023. The AMA has surveyed physicians on prior authorization every year and the numbers have not improved much. So the first question we were asked on Tuesday morning was whether any of this is real. Our answer: some of it is already required by regulation for government programs and this pledge extends it to commercial plans; some of it is new; all of it is voluntary. The right response is to design your prior authorization workflow to take advantage of the parts that happen and to be no worse off if they don't.
Key takeaways
- Six commitments with two deadlines: reductions in the scope of prior authorization, continuity of care on plan changes and clearer denial letters by January 1, 2026; FHIR-based electronic submission and 80% real-time responses on complete electronic requests by 2027.
- For MA, Medicaid managed care and marketplace plans, the 72-hour and seven-day decision timelines and the FHIR API were already required by the CMS-0057-F rule. The pledge's real addition is commercial coverage, continuity of care and the real-time target.
- The practices that benefit will be the ones submitting electronically with clinical documentation attached. A fax log gets none of it.
- Build the baseline now: authorization requests by payer and CPT for the first half of 2025, so you can tell in 2026 whether anything changed.
- Watch medical record requests and post-payment reviews in 2026 as closely as prior authorization volume; that is where friction tends to move.
What was actually promised
| Commitment | Deadline | What it would mean in practice |
|---|---|---|
| Standardized electronic prior authorization using FHIR-based APIs | Operational by January 1, 2027 | Requests submitted from the EHR with clinical data attached, instead of portals and fax |
| Reduce the scope of services requiring prior authorization | Demonstrated reductions by January 1, 2026 | Fewer codes on each plan's PA list; each plan decides which |
| Honor existing authorizations when a patient changes plans | Starting January 1, 2026, for a 90-day transition period for benefit-equivalent in-network services | No repeat authorization for an ongoing course of treatment when coverage switches mid-course |
| Real-time responses for electronic requests | At least 80% of electronic requests with complete clinical documentation answered in real time by 2027 | Approvals at the point of ordering for routine services |
| Clear explanations of determinations and appeal rights | By January 1, 2026 | Denial letters that say what was missing and how to appeal |
| Medical professional review of clinical denials | Affirmed as current practice | Non-approvals based on clinical judgment are reviewed by a clinician |
How this relates to the CMS rule already on the books
In January 2024 CMS finalized the Interoperability and Prior Authorization final rule, CMS-0057-F. It requires Medicare Advantage plans, Medicaid and CHIP managed care plans and marketplace qualified health plans to decide urgent prior authorization requests within 72 hours and standard requests within seven calendar days beginning in 2026, to give a specific reason for denials, to report prior authorization metrics publicly, and to implement a FHIR-based prior authorization API by January 1, 2027. Commercial employer plans are outside that rule. The June 23 pledge extends similar commitments to commercial plans voluntarily and adds the continuity of care provision and the 80% real-time target, which the rule does not contain.
So a practice with a heavy Medicare Advantage and Medicaid managed care mix will see the timeline and transparency changes in 2026 whether or not the pledge holds, because they are regulatory. A practice with a heavy commercial mix is relying on the pledge for the same improvements.
Designing the workflow now
The plans that keep these promises will do so through electronic channels. A practice that still runs prior authorization from a fax log and a spreadsheet will not benefit, because the real-time approvals and the FHIR submissions require the request to originate in a system that can carry clinical data. Here is what we suggest building over the next twelve months, in order.
- A single authorization record per request, in the practice management system or a dedicated tool, with fields for payer, member, ordering provider, CPT and ICD-10-CM codes, date requested, channel used, reference number, decision, decision date, approved units and dates, and appeal status. If this record does not exist you cannot measure anything below.
- A payer-by-code PA requirement table for your top payers and your top 50 procedure codes, reviewed quarterly. When plans reduce their lists in 2026, this table is where you will see it and stop requesting authorizations you no longer need.
- Electronic submission wherever a payer offers it, today through portals and the 278 transaction, and by 2027 through the FHIR API if your EHR vendor implements it. Ask your EHR vendor now whether they plan to support the CMS-0057-F prior authorization API; the vendors that answer clearly are the ones to stay with.
- Clinical documentation attached at submission. The 80% real-time target applies to requests with complete documentation. A request that goes in without the imaging report or the conservative therapy notes will be pended regardless of the pledge.
- A plan-change check at scheduling. From January 2026, a patient who switched plans mid-treatment should not need a new authorization for 90 days under the pledge. The front desk needs to know the patient changed plans and the authorization team needs to cite the continuity commitment when the new plan asks for a fresh request.
A worked example of the baseline
An orthopedic practice with six surgeons pulls its first-half 2025 numbers and finds 2,140 prior authorization requests across five payers, with 61% submitted by portal, 30% by fax and 9% by phone. Median time to decision is 4 days for portal requests and 9 days for fax. 14% of requests were pended for missing documentation, almost all of them MRI and injection requests that went in before the conservative therapy notes were attached. 6% were denied and 40% of those denials were overturned on peer-to-peer. That is a baseline. In July 2026 the same report will show whether the request count fell (the reduction commitment), whether the pend rate fell (the documentation change is the practice's own), and whether the median decision time moved (the regulatory timelines and the real-time target). Without the first report, the second one means nothing.
The numbers to watch
Four measures, monthly, by payer: the share of your scheduled services that required a prior authorization (this should fall in 2026 if the pledge is kept); median days from request to decision; the share of denials with CARC CO-197 (precertification absent) and CO-15 (authorization number missing or invalid), which measure your own process rather than the payer's; and the peer-to-peer and appeal overturn rate, which tells you whether the plan's clinical review is working. Practices that have these four numbers in January 2026 will be able to say, payer by payer, whether the pledge changed anything. Practices that do not will be guessing.
Our view
We are cautiously in favor, with two reservations. The commitments have deadlines but no penalties, and "demonstrated reductions" leaves each plan to define its own baseline. And the pledge says nothing about the volume of medical record requests and post-payment reviews, which in our experience is where plans shift friction when prior authorization is reduced. Watch your records request volume in 2026 as closely as your prior authorization volume.
Revelrex manages prior authorization tracking and authorization-related denials within denial management, and the authorization workflow is one of the front-end processes reviewed in the RCM audit. If you want to talk through what the 2026 changes mean for your payer mix, book a call.
Questions we hear
Does the pledge mean fewer prior authorizations starting now?
No. The reduction commitment is for January 1, 2026, and each plan decides what to remove. Some plans have announced specific reductions already; most have not. Keep requesting authorizations exactly as each plan's current list requires.
Is this the same as gold carding?
No. Gold carding exempts individual providers with high approval rates from prior authorization for certain services, and several states have passed laws requiring it. The pledge is about reducing the list of services and speeding up decisions for everyone. Both can apply at once.
Our biggest payer is a self-funded employer plan administered by one of the signatories. Are we covered?
The pledge covers the signatories' commercial business in general terms, but self-funded plans set many of their own rules. Ask the administrator directly which commitments apply to that plan.
What to do this month
- Pull a count of prior authorization requests by payer and CPT for the first half of 2025, with channel, decision time, pend rate and denial rate. This is your baseline for judging the 2026 reductions.
- Build or clean up the authorization record so every request has a reference number and a decision date.
- Ask your EHR vendor about FHIR prior authorization support in writing.
- Read each top payer's current prior authorization list and calendar a re-read for January 2026.
- Move the fax and phone requests that can go by portal or 278 to those channels, starting with the payer that has the highest volume.
