Modernizing Prior Authorization: Progress on Our Commitments to Members and Providers
04/07/2026
SinceJune of 2025,о hasfocused on translatingto improve prior authorization into tangible changes that make a real difference forour more than 27 millionmembers andtheirproviders. This work is grounded in a simple goal: reduce unnecessary complexity while preserving the safeguards that supportappropriate,high-qualitycare. The result is meaningful progress that is already improving how prior authorization works across our plans.
Since announcing our commitments, о has made measurable progress across several key focus areas:
Improving communication:We redesigned prior authorization communications based ondirect research with memberswho had recently experienced a denial or appealensuring explanations are clearer, more empathetic, and easier to navigate.
Enhancingcontinuity of care:Building ona strong foundationof existing continuity of care operations and to furthersupport members during plan transitions, weenhanced support to members through updated policies. Thisenableshonoring ofprior authorizations from a member’spreviousplan for the same service, under the same benefit type, with an in-network provider, for a90-daytransition period.
Reducing scope:о is removing prior authorization requirements for select codes across multiple lines of business through a structured, multiphase, clinician-led review that evaluatesutilization, approval rates, and evidence-based guidelines to keep prior authorization targeted andappropriate.For example, beginning in Q4 2025, changes focused on imaging services are expected to eliminate approximately 300,000 prior authorizations annually across Medicare and Marketplace plans while preserving review forhigherriskservices.
Modernizing processes:We implemented internal improvements including enhanced customer service and clinical team training, provider portal andtechnicalenhancementsthathelp providers understand coverage rules and documentation requirements earlier in the process.
Maintaining Human Review:As has always been our process, any denials are reviewed by a licensed medical professional.
“о has beenintentionallyinvesting in solutions that make itsimplerfor providers to work with us andhelpmembers access care,” said CEO Sarah London.“The progress we’remakingreflects a focus on reducing unnecessary complexity, modernizing our processes, andcreatinga more predictable and transparent experiencefor those we serve.”
Whilewe’reproud of the progress made, we know there is more to do.We will continue investing in solutions that supportsimplified processes, clearercommunicationand better experiences,collaborating with AHIP and otherpayers to modernize prior authorization to ensurehealthcare is simpler and more accessible for the communities we serve.