Prior Authorization Automation

Prior authorization is a health plan's requirement that a provider get approval before certain services, drugs or procedures. Prior authorization automation uses software to check whether approval is needed, gather the required documents, submit the request, track its status and flag denials, so staff spend less time on phone calls, fax and portal checking.

The rules are changing

The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), released in January 2024, applies to Medicare Advantage organizations, state Medicaid and CHIP programs, Medicaid managed care plans and qualified health plan issuers on the federally facilitated exchanges. It requires most affected payers to send decisions within 72 hours for expedited requests and seven calendar days for standard requests, starting in 2026, and to give a specific reason for denials. It also requires payers to build a Prior Authorization API based on HL7 FHIR, with most API requirements starting in January 2027. Check the CMS page for the exact dates that apply to each payer type.

What can be automated now:

Requirement checks

Look up whether a service needs prior authorization for a given plan before the visit is scheduled.

Packet assembly

Pull the order, notes, diagnosis codes and supporting records into one submission.

Status tracking

Check payer portals or APIs on a schedule and update the practice system.

Denial handling

Route denials to staff with the stated reason and a draft appeal.

What should stay with people

Clinical judgment, what to say in an appeal and any communication that changes a patient's care plan. Automation prepares and tracks; staff decide.

Data protection

Prior authorization involves protected health information, so every vendor that touches it needs a business associate agreement and access controls. In our builds for medical and dental practices we start with the payers and services that create the most rework and keep staff approval on every submission.