The new administration shed light on policy issues at the top of providers’ lists for 2025. While topics like physician burnout and Medicare payment reform were included, unsurprisingly, prior authorization remains at the forefront, as proven by entities like the American Medical Association, who represent more than 270K providers. Improvements in the prior authorization and interoperability space have been historically stalled due to lack of standard data and public reports, as technology involved in these processes hasn’t changed much in the last 30 years. However, this is set to change in 2026 and 2027 with CMS’ Interoperability and Prior Authorization Final Rule.
This final rule focuses on improving prior authorization processes through policies and technology, improving health information exchange between all stakeholders, and reducing overall payer, provider, and patient burden through improvements to prior authorization and data exchange practices. Not only do these changes aim to improve current inefficient processes, but the overall consumer experience as well.
While these changes won’t take effect for another year, payers and providers must prepare now to stay compliant with the Final Rule. While the changes may feel daunting with the stalled innovation for the past three decades, payers and providers can tackle these changes head on with technology, but it will take time and money and require a strategic approach.
The changes related to prior authorization timelines and claims
Starting in 2026 and 2027, payers will have to meet certain provisions. Impacted payers will be subject to more stringent prior authorization turnaround requirements, with a seven calendar-day period for standard requests, and a 72-hour window for expedited requests. While some payers currently adhere to these timelines voluntarily already, this new regulation will mean compliance becomes obligatory, making it necessary to align operations, technology, and staff to facilitate timely adherence.
Providers will also undergo significant modifications. With the new regulations stipulating that payers must provide specific denial rationales and instead of just code numbers, providers will benefit from enhanced clarity regarding the reasons for authorization denials and have better access to longitudinal patient data with a more holistic view of their medical history. This advancement will enable providers to advocate more effectively for their patients, proactively adjust care plans, and refine documentation practices to mitigate the likelihood of future denials.
Another notable transformation for providers involves the provision of real-time updates on prior authorization status through Application Programming Interfaces (API) integrations. This increased transparency will eliminate the need for unnecessary phone inquiries and manual follow-ups, allowing providers and staff to concentrate on patient care. Consequently, this will streamline clinical workflows and alleviate the long-standing administrative burdens faced by provider organizations. These adjustments will empower providers with real-time and actionable information, enhancing their ability to guide clinical decisions, communicate with patients, and contest denials when warranted. This, in turn, fosters the strengthening of patient trust and collaboration throughout the continuum of care.
Ultimately, healthcare providers will be able to perform all necessary tasks like pre-authorization checks, completing prior authorization questionnaires, submitting prior authorization requests, and automating prior authorization status checks—directly within their electronic health records. These changes aim to conserve valuable time for the provider and their supporting staff.
How technology plays a role in supporting organizations amid changes
These changes show promise in improving processes for payers and providers and ultimately making for a better patient experience, but key to meeting these requirements ahead of next year will be the implementation of robust, future-ready technology, and ensuring providers invest in staff training for its use. Technology solutions are strategically positioned to function as enablers of compliance, operational efficiency, and patient-centered care.
For example, portals can assist providers by facilitating seamless access to real-time prior authorization statuses, enabling staff to monitor authorization progress without reliance on manual communications, and prompting reminder alerts to mitigate delays and ensure timely follow-ups. This provides a significant advantage in addressing the tighter authorization decision windows coming with the changes. Additionally, providers can benefit from a consolidated source of truth for authorization requests, which diminishes administrative burdens and optimizes workflows. In the background, technology with Fast Healthcare Interoperability Resources (FHIR) APIs enable real-time data exchange among providers, payers, and patients. These APIs permit clinical systems to automatically submit prior authorization requests, retrieve decision statuses, and obtain comprehensive explanations for denials. This functionality alleviates the need for providers to navigate disparate systems or avoid long wait times for updates, enhancing their capacity to make informed decisions and communicate effectively with patients.
In addition to supporting workflow efficiency, these technologies empower providers to generate, capture, and analyze the data required under the new reporting mandates. For example, timelines between submission and decision, denial rates, and decision turnaround times can be logged and analyzed on a platform, supporting provider organizations in maintaining compliance while identifying operational deficiencies and areas for improvement.
Looking to the future, payers and providers that find the right partner for technology and embrace these tools proactively will be better positioned to adapt to evolving requirements from the Interoperability and Prior Authorization Final Rule, minimize administrative overhead, and ultimately deliver higher-quality, more timely care.
A compliant-ready future with cross-stakeholder and vendor collaboration
The upcoming Interoperability and Prior Authorization changes will enable payers and providers to capture more data about members than ever before for increased understanding of medical necessity, cost reduction and improved authorization processes and timelines. In fact, according to CMS estimates, implementing the Interoperability and Prior Authorization Final Rule will save providers 206 million hours on administrative tasks, which translates to $15 billion in cost savings over the next decade.
Instead of just ticking boxes to remain compliant, the role for payers will shift and allow them to become a more engaged and active participant in supporting patient outcomes through increased transparency and better overall experience. On both the provider and patient side, more insight and transparency into claim denials will be available, as well as access to data for coverage and treatment options for optimal health outcomes. Payers and providers should strive to work with partners for support to adhere to upcoming prior authorization changes. Investing in technology now and ensuring staff are given adequate training over the next calendar year, instead of waiting until the last minute, will enable organizations to maximize on collected data and remain compliant, when the Interoperability and Prior Authorization Final Rule takes effect in 2026 and 2027.
About Reva Sheehan
Reva Sheehan is the Senior Director of Consumer Insights at mPulse, a leader in digital solutions for the healthcare industry, is transforming consumer experiences to deliver better, more equitable health outcomes. Reva has more than 15 years’ industry experience ranging from health plan quality and pharmacy operations to long term care and compound pharmacy management. In her current role, Reva ensures mPulse’s programs and products are aligned with regulatory requirements and market drivers to best support their healthcare clients and the individuals they serve.
