Seeking clarity in prior authorization data from insurers

The American Medical Association is citing progress in getting more information from health insurance companies about prior authorization policies.

The Centers for Medicare & Medicaid Services has clarified its guidance to health insurers about what they need to do to comply with new rules designed to shed more light on the prior authorization process.

The AMA says it welcomes the new federal guidance. The nation’s largest organization representing physicians had said insurers were providing incomplete information that was difficult for consumers to find, much less understand if they did discover it.

Willie Underwood III, MD, president of the AMA, said in a news release that plans submitted information that wasn’t in plan language, or was only accessible after signing in via patient portals.

“Patients should not need a portal password, a billing manual or medical training to find and understand a health plan’s prior authorization practices,” Underwood said in a statement.

Here are a few key elements of the new CMS guidance.

Making it public

CMS is making it clear that patients should be able to get on a health plan’s site and get information about prior authorization policies.

“Posting the required metrics only through password-protected provider or member portals or in other locations that cannot be reached through ordinary navigation from the payer’s public-facing website does not satisfy the ‘publicly accessible’ requirement of the final rule,” CMS says.

Specify services requiring approval

Health plans must clearly outline all medical items and services that require prior authorization, CMS says.

The AMA argued that insurers weren’t always including certain services requiring approval, including behavioral health and post-acute services.

Understandable language

CMS is telling health plans that they must provide “plain language descriptions of each item or service” that falls under prior authorization requirements.

More specifics on time

Health plans are advised that they have to use specific measurements of time, such as calendar days or hours. If a turnaround time is less than a day, plans should specify how many hours, instead of “0 days.”

Charts and numbers

CMS says insurers should use bar charts and pie charts to present data on delays in approval decisions. The administration also wants more precise data.

“We highly recommend reporting both counts and percentages so the public can understand the scope of requests,” CMS says.

A long-running battle

Doctors and health systems have long argued that insurers are denying or at least delaying treatments too often, saying that patients are paying the price and providers are dealing with too many costs and hassles in securing approval from health plans. AMA surveys have found the vast majority of doctors say prior authorization is hurting patient care, with some abandoning treatment after denials.

Insurers say the prior authorization process is necessary to contain healthcare costs and to curb unnecessary procedures.

Health plans are also working under new federal rules to speed up the timelines on approval requests. Insurers must respond within 72 hours for expedited requests, and within seven days for standard requests. Previously, insurers had twice as long to respond. The rules took effect Jan. 1, 2026, but they were approved in 2024.

Physicians have said even the revised timelines are too long, and that approvals, particularly in urgent cases, should come more quickly. In May, the AMA sent a letter to CMS outlining areas where it said health plans weren’t complying with federal requirements.

Insurers also are required to disclose denial rates to CMS, and how long they are taking to make decisions on authorization requests.

Health insurance companies publicly committed last year to ensuring that 80% of authorizations will be handled in real time by 2027, according to AHIP, the trade group representing health insurance companies. Health insurers have also vowed to standardize electronic prior authorizations and reduce the volume of treatments that require pre-approval.