On June 23, 2025, health insurance plans revealed significant commitments aimed at simplifying and streamlining prior authorizations for better care access. These initiatives are built on existing efforts to enhance patient connections to necessary care while reducing the administrative burden on healthcare providers. Such changes promise to improve overall patient experience and access to evidence-based treatments, aligning with the industry’s goal of delivering affordable healthcare.
In line with state and federal regulations, new commitments across insurance segments aim to enhance health coverage for 257 million Americans. The six key commitments focus on :
- Standardizing electronic prior authorization: Highmark is already compliant with the Center for Medicare and Medicaid Services (CMS) final rule and have planned to make these capabilities available beyond Medicare.
- Reducing the scope of claims subject to prior authorization: Highmark’s Utilization Management team is reviewing all codes and service categories on the prior authorization list and will recommend reductions.
- Ensuring continuity of care when patients change plans: Highmark already accepts most approved prior authorizations for members who are new to our coverage.
- Enhancing communication and transparency on determinations: Highmark is working to improve member and provider communications and evaluating other operational activities to better support members through a denial.
- Expanding real-time responses: Highmark and our provider community have already increased the number of electronic submissions to 76%. With the adoption of standardized Fast Healthcare Interoperability Resource Application Programming Interfaces (FHIR APIs) across all markets and increased portal adoption from providers, we anticipate achieving the 80% response rate by 2027.
- Ensuring medical review of non-approved requests: Highmark already conducts medical and peer-to-peer review of denied prior authorizations.
These steps are crucial for improving the overall health insurance landscape and fostering better patient experiences.
We are dedicated to providing exceptional service, so please do not hesitate to contact our dedicated Total Benefit Solutions health insurance specialists at (215)-355-2121 or fill out the contact form below. We are available to answer any questions or address any concerns you may have.