US Insurers Move to Harmonize Prior Authorization Data and Submission Rules

UnitedHealth and CVS Health said they have standardized data and submission requirements for a majority of prior authorization requests, part of a sector-wide push to reduce administrative burden and delays for clinicians and patients. UnitedHealthcare expects over 70% of requests to follow the standardized process by year-end, while CVS Health's Aetna unit has standardized 88% of its prior authorization volume. The changes apply to commercial, Medicare Advantage and Medicaid lines and target commonly authorized services such as orthopedic procedures and imaging.

Key Points

UnitedHealthcare expects over 70% of prior authorizations to follow a standardized submission process by year-end, covering commercial, Medicare Advantage and Medicaid plans - impacts health insurers, healthcare providers, and health services utilization.
CVS Health's Aetna unit has standardized 88% of its prior authorization volume - affects insurance administration and provider billing workflows.
Standardization focuses on commonly authorized services such as orthopedic surgeries and imaging (CT, MRI) and aims to reduce rework and requests for additional information - relevant to hospitals, outpatient imaging centers, and medical practices.

April 24 - Two of the largest U.S. health insurers announced on Friday that they have implemented standardized data and submission requirements for a significant share of prior authorization requests, an initiative intended to ease paperwork and shorten processing times for patients and providers.

UnitedHealth and CVS Health said the work is part of a broader industry effort to follow through on commitments to reduce administrative complexity in prior authorization for medications and medical services. Insurers have come under scrutiny to simplify the forms and information required to obtain approvals before care is provided.

UnitedHealthcare, the insurance arm of UnitedHealth, stated it plans to have more than 70% of prior authorization requests handled under the standardized process by the end of the year. The company said this effort will cover requests across its commercial plans as well as its Medicare Advantage and Medicaid lines.

CVS Health said its Aetna insurance unit has standardized 88% of the prior authorization requests it receives. Both insurers emphasized that the new approach focuses on aligning the information health plans require to support authorization decisions.

The standardized process targets medical services that are frequently subject to prior authorization, including orthopedic surgeries and imaging services such as CT scans and MRIs, according to the industry group AHIP. UnitedHealthcare described the goals as improving predictability, cutting down on rework and reducing the frequency with which plans must ask for additional information from providers.

UnitedHealthcare also said it plans to expand the standardized program to a broader set of medical services over time and to continue reducing the number of procedures that require prior approval. The insurer noted that these changes will not alter coverage guidelines or the clinical criteria used to approve or deny care.

Context and implications

By aligning data fields and submission expectations, the insurers aim to make prior authorization workflows more consistent for clinicians working across different payers and for patients seeking timely care. The moves are presented as administrative reforms rather than changes to what treatments are covered clinically.

What remains limited in the announcements

The statements do not change clinical coverage rules or the medical rationale used in approval decisions.
Details on timelines for expanding the standardized approach to additional services beyond those identified were described as planned but not specified in scope or timing.

Risks

The announcements do not alter coverage rules or clinical criteria, so patients and providers may still face denials based on medical necessity - risk affects patient access and provider revenue.
Plans to expand standardization to more services and to cut procedures requiring prior approval were described but without detailed timelines or scope - introduces uncertainty for providers and payers about when operational benefits will fully materialize.
Reducing administrative steps depends on consistent adoption across payers and providers; incomplete implementation could limit expected reductions in delays and paperwork - risk impacts administrative operations across the healthcare sector.

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