A Promising Step Forward: What the Payer Pledge Means for Prior Authorization

Prior authorization (PA) has long been a source of friction in the U.S. healthcare system. For providers, it’s a significant administrative burden marked by manual processes, inconsistent communication, and outdated technology. For patients, delays in treatment caused by the fragmented PA process create stress and disruptions to care. 

Thankfully, the industry is entering a major shift to improve prior authorization for providers, patients, and payers. In alignment with the upcoming CMS-0057 regulation, around 50 health insurers have voluntarily signed a pledge to improve prior authorization. This pledge signals real progress in cutting administrative red tape and modernizing the patient-provider experience. It also reflects a growing consensus that improving prior authorization is critical to delivering timely and effective patient care.

How Health Plans Are Stepping Up

Led by AHIP, in partnership with the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS), the pledge outlines six key commitments providers are making to streamline the PA process. It directly addresses the longstanding concerns from providers, patients, and policymakers.  

Major health plans have signed on to the pledge, including six of the largest insurers: Centene, Cigna, Humana, UnitedHealthcare, CVS Health’s Aetna, and Elevance Health. Together, they’re committed to reimagining prior authorization and moving toward a modern, patient-centered process in line with 21st-century standards and the expectations set by CMS-0057.   a demo.

Why It Matters: Fixing a Fragmented System

Prior authorization remains a significant obstacle in delivering timely, high-quality patient care. Patients often wait days or even weeks for approvals before receiving treatment, in some cases, significantly risking their health. According to the American Medical Association’s 2024 AMA prior authorization physician survey, 93% of physicians say that PA delays care, and 23% report that PA has led to a patient’s hospitalization.

For providers and their teams, countless hours are lost to appeals, phone calls, faxes, and paperwork. For payers, this inefficient system translates to higher costs, provider dissatisfaction, and lower quality of care. This system-wide fatigue is exactly what the pledge aims to fix. It reflects not only the regulations outlined in CMS-0057 but also genuine empathy for the human toll that PA inefficiencies create. Payers recognize the status quo is no longer sustainable. 

As Mike Tuffin, AHIP President and CEO noted, “The health care system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike. Health plans are making voluntary commitments to deliver a more seamless patient experience and enable providers to focus on patient care, while also helping to modernize the system.”

Inside the Payer Pledge: 6 Key Commitments

The pledge includes six core commitments that payers have voluntarily agreed to adopt, designed to streamline and modernize the PA process:

• Standardizing electronic submissions via FHIR® APIs. Plans will adopt FHIR®-based APIs to enable seamless, transparent submissions for electronic PA. 
• Reducing the number of services needing approval by January 1, 2026. Health plans will evaluate and reduce the number of services requiring prior authorization, promising demonstrated reductions by 2026.
• Honoring existing authorizations during insurance transitions. To support continuity of care, plans commit to honoring active authorizations when members change insurers as part of a 90-day transition period.
• Increasing transparency around denials and appeals. The pledge ensures clearer communication about why requests are denied and support for appeals.
• Delivering real-time responses on 80% of electronic requests by 2027. By leveraging APIs and automation, payers aim to respond in real-time to 80% of all electronic PA requests.
• Guaranteeing medical review of all clinical denials. Payers affirm that medical professionals will review all denials based on clinical reasons—a commitment already in effect.

These commitments lay the foundation for a more connected and effective prior authorization process that will positively impact patients and the providers who care for them.

Why Choosing the Right Tech Partner Is Critical

With the pledge in motion and CMS-0057 deadlines approaching, payers are under pressure to modernize their PA systems quickly. However, how they do it and with whom they partner will determine their success.

The right technology partner can mean the difference between simply checking a regulatory box and proactively transforming your PA operations in a scalable, provider-friendly way that drives real ROI. That’s why payers are seeking proven vendors who not only thoroughly understand the technical requirements of CMS-0057 but also bring holistic, forward-thinking solutions.

One payer who understood this early is Cox HealthPlans. In their search for a partner, they weren’t only focused on compliance and meeting deadlines—they sought a cost-effective solution that would integrate seamlessly across all provider channels, simplify workflows, and have a meaningful impact on patients.

See how Cox HealthPlans chose Itiliti Health as their partner. In this video, Susan Sanchez, Chief Information Officer, shares the key considerations that went into their partner selection process and why Itiliti Health stood out as the clear choice. 

How Itiliti Health Helps Payers Deliver on the Pledge

At Itiliti Health, we believe prior authorization should be efficient, transparent, and scalable. Our solutions are designed to help payers deliver on the promises made by the pledge and transform PA into a seamless process for providers and patients. 

We support payers with:

• A secure, HIPAA-compliant platform that meets state and federal regulations
• Automated prior authorization workflows that reduce decision times and administrative burden
• API solutions designed for seamless integration with existing systems
• Transparent dashboards and robust reporting

Our platform isn’t just about meeting compliance requirements. It’s built for efficiency, cost savings, and provider satisfaction. If your organization is evaluating PA partners, we’re ready to help you take the lead in this transformation, not just keep up.

Looking Ahead

The payer pledge represents a powerful moment of alignment in U.S. healthcare: policymakers, insurers, and health systems are all committed to reforming prior authorization. Momentum is building towards a fast, transparent, and modern process that works better for everyone.

With CMS-0057 deadlines approaching, the time for payers to act is now. With the right partner, prior authorization can transition from a bottleneck to a streamlined process that enhances patient care while reducing administrative burden on providers.

At Itiliti Health, we’re proud to support payers in pushing this transformation forward. Contact us today to discover how we can support your organization during this transition and beyond.