Why Prior Authorization Takes So Long and How Automation Is Changing It

Your doctor orders an MRI, a surgery or a new medication. Then nothing happens. Days pass while the office waits for your insurer to say yes. You call the office, the office says they’re waiting on the plan, and the plan says it’s waiting on paperwork.

That limbo is prior authorization, and it frustrates patients and clinicians alike. In the American Medical Association’s 2025 physician survey of 1,000 doctors, physicians reported completing an average of 40 prior authorizations a week, and 95% said prior authorization delays access to necessary care.

The process is changing, though. Federal deadlines took effect in 2026 for many public-program health plans, electronic prior authorization requirements arrive in 2027, and large insurers have made public pledges to simplify approvals. This guide explains why the wait happens, what’s actually changing, and what you can do today to move your request faster.

What prior authorization is and why insurers use it

Prior authorization (also called preauthorization or precertification) is approval your health plan requires before it agrees to cover certain care. Common examples include advanced imaging like MRIs and CT scans, planned surgeries, specialty drugs, durable medical equipment, and stays in rehab or skilled nursing facilities.

Insurers say it helps confirm that care is medically necessary, follows evidence-based guidelines and avoids waste. Critics say it delays care and adds paperwork. Both views show up in government reviews. For example, a 2022 report from the HHS Office of Inspector General found that among prior authorization requests that Medicare Advantage organizations denied, an estimated 13% met Medicare coverage rules and likely would have been approved under Original Medicare.

Why prior authorization takes so long

The delay usually isn’t one big problem. It’s several small ones stacked together.

Manual, disconnected systems

Many requests still move by fax, phone or a different web portal for each insurer. Staff re-type information from the electronic health record into a payer’s form, then wait for a reply that may come back through yet another channel.

Every plan has different rules

Each insurer, and often each plan within an insurer, has its own list of services that need approval and its own clinical criteria. Office staff have to look up the rules for every request, and those rules change.

Missing or mismatched documentation

If a request lacks a clinical note, test result or proof that a cheaper treatment was tried first, the plan asks for more information. Each round trip can add days. The OIG report found that requests for unnecessary documentation were one cause of denials that met Medicare rules.

Review queues and peer-to-peer calls

Some requests go to a clinical reviewer. If the plan leans toward denial, your doctor may need a “peer-to-peer” call with the plan’s medical reviewer, which has to be scheduled around patient care.

Denials, appeals and resubmissions

A denial isn’t always the end. Many denials are overturned on appeal, but the appeal itself adds time. Some offices resubmit corrected requests instead of appealing, which restarts the clock.

Key takeaway: Most prior authorization delays come from paperwork moving between systems that don’t talk to each other. That’s exactly what the new electronic rules target.

What the federal rules now require

The biggest change is the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), finalized in January 2024 and effective April 8, 2024. It applies to “impacted payers”: Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid and CHIP managed care plans, and qualified health plan issuers on the federal marketplaces. It does not cover most employer plans.

Medicare Advantage has another protection worth knowing. Under CMS’s 2024 Medicare Advantage final rule (CMS-4201-F), coordinated care plans must give a minimum 90-day transition period when an enrollee in active treatment switches to a new Medicare Advantage plan, and an approved course of treatment must stay valid as long as medically reasonable and necessary.

What’s proposed but not final

In April 2026, CMS released a proposed rule (CMS-0062-P) that would extend electronic prior authorization to prescription drugs, with most proposed requirements starting October 1, 2027. Because it’s a proposal, the details could change. Check CMS’s electronic prior authorization page or the Federal Register for the final version.

Original Medicare is testing prior authorization too

Traditional Medicare has historically used prior authorization for only a few services. CMS’s WISeR Model, which runs from 2026 through 2031 in 6 states (Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington), tests prior authorization for selected services using technology vendors with clinician review. CMS says providers can choose to skip the request, but those claims then face pre-payment medical review.

This is not legal advice. Rules and dates can change, so confirm details with your plan or CMS.

How automation is changing prior authorization

“Prior authorization automation” covers several tools that cut the manual steps.

• FHIR-based APIs. FHIR is a modern standard for exchanging health data. The required Prior Authorization API lets an EHR ask the plan, in real time, whether a service needs approval and what documents it needs, then submit the request electronically.
• Coverage requirement lookup. Instead of staff searching payer websites, the EHR can show the rules inside the ordering screen. That stops many requests before they’re needed and makes the rest complete on the first try.
• Automatic documentation gathering. Software can pull the relevant notes, lab results and imaging reports from the chart and attach them, so plans get what they need without a follow-up call.
• Auto-approval for clear-cut cases. When a request clearly meets criteria, the plan’s system can approve it in seconds. In their June 2025 pledge with HHS, major insurers committed to real-time approvals for most electronic requests by 2027.
• AI review support. Some plans and vendors use AI to sort and pre-review requests. The insurer pledge commits that medical professionals review all clinical denials. Automated tools can speed approvals, but they don’t replace your right to a human clinical review or an appeal.

On the provider side, prior authorization tools are often part of revenue cycle management software or built into the EHR. Practices choosing a system should ask about it; our guide on how to choose an EHR for a small practice covers what to look for.

The industry pledge: what insurers promised

On June 23, 2025, HHS and CMS announced voluntary commitments from major health insurers covering Medicare Advantage, Medicaid managed care, marketplace and commercial plans. The insurers pledged to:

1. Standardize electronic prior authorization using FHIR-based APIs
2. Reduce the volume of services subject to prior authorization, starting by January 1, 2026
3. Honor existing authorizations when patients switch plans
4. Improve transparency and communication about decisions and appeals
5. Provide real-time approvals for most requests by 2027
6. Ensure medical professionals review all clinical denials

These are voluntary promises, not regulations. CMS publishes progress snapshots on its electronic prior authorization page. The AMA’s May 2026 survey release reported that only 1 in 3 physicians believed the pledge would make a meaningful difference, so it’s worth watching whether your own plan’s experience improves.

What patients can do to speed up approval

You can’t control your insurer’s queue, but you can remove the most common causes of delay.

1. Ask at the appointment. “Does this need prior authorization, and who will submit it?” Get the name of the person or team handling it.
2. Get the reference number. Once the request is submitted, ask for the authorization or case number and the submission date.
3. Check the deadline that applies to you. If you have Medicare Advantage or Medicaid, plans subject to the CMS rule generally must decide standard requests within 7 calendar days and urgent ones within 72 hours.
4. Ask for an expedited review when it’s urgent. If waiting could seriously harm your health, your doctor can request expedited handling.
5. Call your plan directly. Use the member services number on your card. Ask whether the request is complete or whether anything is missing, then pass that to your doctor’s office.
6. Use your apps. Your plan’s member portal and, from 2027, apps connected through the Patient Access API can show request status. Our guide to using a patient portal explains the basics.
7. Appeal a denial. Read the denial reason, ask your doctor to submit supporting records, and file an internal appeal. If that fails, you may be eligible for an external review.
8. Confirm in-network status. Approval doesn’t help if the provider is out of network. Our guide on how to check if a doctor is in network shows how.

If you get a bill after an approved service, compare it with your explanation of benefits using our guide on how to read a medical bill.

Where to start if you run a practice

If you’re on the provider side, start small:

• Measure first. Track how many requests you submit, turnaround time by payer, and denial reasons for 30 days.
• Ask your EHR vendor about support for the Da Vinci prior authorization standards and the Prior Authorization API timeline.
• Use payer portals that integrate with your EHR before adding standalone tools.
• Build templates for your most common requests so documentation is complete the first time.
• Watch payer metrics. Plans subject to CMS-0057-F publish approval and denial statistics you can use to plan staffing.

For broader context on how health systems are adopting these tools, see our overview of AI in healthcare in 2026.

The bottom line

Prior authorization takes so long mainly because paperwork moves slowly between disconnected systems and every plan has its own rules. Federal deadlines in 2026 and electronic API requirements in 2027 should shorten waits for many Medicare Advantage and Medicaid patients, and insurer pledges aim to extend real-time approvals more broadly. Until then, the best thing you can do is know who submitted your request, track it, and appeal if a denial doesn’t make sense.

This is general information, not medical advice.

Sources

• CMS: Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheet — decision timeframes, denial reasons, metrics and API dates
• CMS: Electronic Prior Authorization overview — industry commitments, proposed drug rule and WISeR context
• CMS: HHS Secretary Kennedy, CMS Administrator Oz secure industry pledge to fix prior authorization — the 6 insurer commitments
• CMS: 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) — 90-day transition period
• HHS OIG: Some Medicare Advantage organization denials of prior authorization requests raise concerns (OEI-09-18-00260) — 13% of denials met Medicare coverage rules
• AMA: Survey shows prior authorization reform pledge falls short with physicians — 2025 physician survey figures