A Step Toward Simpler Healthcare Approvals
For many employees and their families, health benefits become especially important when care is needed. When a doctor recommends a test, treatment, medication or procedure, questions about coverage, timing and next steps can quickly follow. This is especially true when prior authorization is required before care can move forward.
Prior authorization is used by health plans to review certain services before they are provided. The process is intended to help confirm that care is medically necessary and covered under the plan. In some PPO plans, this process may be referred to as precertification, particularly for certain services that require advance review.
Typically, the patient’s healthcare provider or care team submits the required information to the health plan, which then reviews the request based on the plan’s coverage and medical necessity requirements.
But when the process is slow, unclear or difficult to navigate, it can create stress for patients, extra work for providers and delays in care.
The good news is that measures are underway to make the process more consistent and less overwhelming. Recently, America’s Health Insurance Plans (AHIP), the national trade association representing health insurance providers, announced that participating health plans are moving toward a more standardized electronic prior authorization system for most medical services by Jan. 1, 2027. The goal is to reduce administrative burden, improve consistency, and help patients and providers receive answers more quickly.
This industry effort is part of a broader shift toward more connected healthcare administration. The Centers for Medicare & Medicaid Services (CMS) recently finalized a rule designed to improve how health information is shared and make certain prior authorization details easier to exchange electronically. Many requirements take effect in 2026 and 2027, including those designed to support electronic prior authorization.
CMS has also proposed additional standards for prior authorization involving prescription drugs, including steps intended to support electronic submissions, shorter decision timeframes and clearer information when a request is denied.
For employers, the takeaway is that the healthcare system is gradually moving toward a more coordinated process. Over time, these changes may help reduce confusion and make it easier for employers, providers and health plans to communicate.
For employees, prior authorization can add another layer of concern when they are already focused on a diagnosis, treatment plan or loved one’s care. A clearer, faster process can help reduce delays, ease confusion and make it easier for employees to move forward with confidence.
The need for improvement is clear. According to industry experts, only 35% of medical prior authorizations are conducted fully electronically. In addition, adopting an electronic standard could save the industry $515 million annually while reducing the time medical providers and staff spend on each authorization by 14 minutes.
Even as prior authorization becomes more streamlined, employees still benefit from knowing where to turn with questions about their coverage. PacFed helps connect employees and families with the plan information, eligibility guidance, bilingual member services, online tools and open enrollment resources they need to take charge of their own health.
This means having a trusted administrative partner behind the scenes to help benefits run more smoothly and give team members clearer guidance when care is needed most.
Make us part of your team
When you’re ready to simplify employee benefits administration and provide a more supportive experience for your employees, PacFed is here to help. Call 800.753.0222 to start the conversation. We’d love to hear from you.
For more information
For more information, members should review their Evidence of Coverage for a full description of benefits, covered services and plan requirements. Members may also find helpful information through the following health and dental plan links:
Kaiser Permanente Authorization
Pacific Federal is a Zenith American company and subsidiary of Harbour Benefit Holdings, Inc.
