2025 Shows Promise for Prior Authorization Automation

By Alix Goss, Senior Consultant, POCP & Program Manager, HL7 Da Vinci Project

By Kendra Obrist, Senior Consultant & Payer Interoperability Subject Matter Expert

Prior authorization (PA) continues to rank among the most persistently reported sources of administrative burden, clinical frustration, and care delays for patients in the American healthcare system. For years, efforts to streamline the process have moved forward in fits and starts, hindered by ineffective standards, siloed data and rules, and a lack of true payer ̶provider collaboration.

But 2025 felt like a turning point, when decades of groundwork ranging from maturing standards like a range of Health Level 7’s Fast Healthcare Interoperability Resources (HL7 FHIR) implementation guides and the National Council for Prescription Drug Programs’ (NCPDP) SCRIPT to policy drivers such as the Centers for Medicare and Medicaid Services (CMS) Interoperability and Prior Authorization final rule (CMS-0057) and the CMS Health Tech Ecosystem Pledges began to create a groundswell. The industry is seeing real, measurable progress toward automation, transparency, and efficiency in PA workflows.

Among all areas where the industry is trying to improve, prior authorization automation stands out as a convergence point of industry agreement reflecting the payoff of sustained collaboration between policymakers, standards bodies, payers, providers, and technology vendors for the betterment of patients.

Automating prior authorizations helps patients get the care they need faster and with fewer surprises. When someone isn’t feeling well, the last thing they should have to navigate is a maze of paperwork and delays just to get a test, treatment, or procedure approved.

This article will first examine what fueled progress in PA automation, then highlight a few honorable mentions for positive motion.

Prior Authorization Automation: The Clear Front-Runner in 2025

After years of pilot projects, incremental policy shifts, and slow technology adoption, PA automation finally broke through in 2025 as an area with important progress for standards-based data exchange. The combination of firm regulatory deadlines, aligned industry pledges, and early production deployments shifted the conversation from “if” to “how fast” full automation could scale.

Policy and Regulatory Momentum

The biggest accelerants are the deadlines associated with CMS-0057, the Interoperability and Prior Authorization Rule, which locked in 2026–2027 compliance dates for prior authorization response times and the Da Vinci FHIR-based application programming interfaces (APIs): CRD (Coverage Requirements Discovery), DTR (Documentation Templates and Rules), and PAS (Prior Authorization Support) and related use of CDex (clinical data exchange). The rule’s 2026 requirement for public transparency into a health plan’s PA activity is an important baseline that will allow the industry to measure progress as automation matures.

At the same time, industry-driven reform pledges began to move the market even before the regulations are scheduled to take effect. The CMS-led PA Reform Pledge encouraged payers to voluntarily commit to faster turnaround times and more transparent criteria, helping normalize the concept of real-time prior authorization across all lines of business. Several states added complementary legislation to eliminate redundant or low-value PA requirements. Notably, California’s SB 306 requires payers to regularly review and streamline their PA lists, aligning with federal goals of reducing administrative burden.

States are also playing an increasingly important role in broadening the reach of federal policy and supporting the implementation process. Washington State Health Care Authority and the Massachusetts Health Data Consortium (MHDC) offer two distinct but complementary approaches. Washington’s legislative model, established under HB 1706, requires payers to meet strict timelines for PA determinations and to deploy FHIR-based APIs integrated directly with provider electronic health records (EHRs). The state’s Payer and Healthcare Provider Workgroups bring health plans, physicians, administrators, and revenue cycle leaders into the process to ensure technology and workflow changes reflect real-world needs.

In contrast, Massachusetts has taken a collaborative, community-driven path. MHDC is evolving its New England Healthcare Exchange Network (NEHEN) into the nation’s first statewide FHIR-based prior authorization and clinical data exchange system. By convening payers, providers, and vendors in a shared governance model, MHDC is replacing manual fax and phone processes with real-time, automated approvals. Together, these state initiatives show how local leadership and stakeholder collaboration can accelerate compliance with federal rules while tailoring implementation to unique regional needs.

Adding to the momentum, the HTI-4 rule introduced certification criteria for prior authorization APIs, ensuring that EHRs and payer systems would be technically ready to support the CMS-0057 framework. Together, these actions provide the policy backbone that finally translates years of standards development into practical, enforceable change.

Industry Pledges, Pilots, and Early Adoption

The federal policy foundation set the stage, but 2025’s real momentum came from visible demonstrations of industry commitment, particularly through the CMS Health Tech Ecosystem Pledges, HL7’s Da Vinci Project Trebuchet pilot program, and ongoing Connectathon testing events. These initiatives are helping translate the promise of standards-based automation into tangible action.

The CMS Pledges brought together payers, health systems, and healthcare information technology (health IT) vendors that voluntarily committed to measurable improvements in prior authorization, interoperability, and data transparency. Public pledges from major organizations signaled confidence in FHIR-based approaches and aligned voluntary market activity with upcoming CMS-0057 requirements. These commitments showed not only intent but also created a sense of shared accountability across the system.

At the same time, the Da Vinci Trebuchet pilot program serves as a proving ground for moving implementation guides from their earliest successes and project infancy into real production use. Trebuchet aims to demonstrate the value of Da Vinci implementation guides by enabling pilots, including CRD, DTR, and PAS workflows across multiple entities. Its mission is to help “launch” payer and provider collaboration into production through collaborating on use-case definitions, problem-solving as a community, sharing knowledge, and organizing pilot work between parties.

Vendor engagement, not just in 2025 but over the past several years, has added further validation, reporting significant operational improvements using evidence-based clinical guidelines and rules-based automation. Cohere Health released its FHIR-enabled Cohere Connect platform to streamline electronic prior authorization (ePA) for medical and specialty drugs. Smile Digital Health publicly documented CMS-0057 readiness and offered commercial modules aligned with Da Vinci guides. Itiliti Health offers solutions that support payers' need to digitize, maintain, and share policies and automate their use throughout the PA process.

Participation in HL7 Connectathons also showcased growing implementation maturity. Epic served as a provider-side FHIR integrator, hosting demonstrations of CRD connectivity within its EHR in collaboration with Itiliti Health. Firely and GenHealth supported implementers through tooling and integration services, while eHealth Exchange shared production-level insights into network-based FHIR exchange and Da Vinci guide adoption at scale.

Together, these efforts illustrate a clear shift from exploration to execution. Industry pledges, collaborative pilots, and active vendor engagement are helping to ensure that PA automation evolves in a coordinated, standards-based manner—one informed by real implementation experience rather than theoretical design.

Technology and Workflow Maturity

The shift from theoretical interoperability to practical automation became increasingly evident in 2025. While many FHIR-based APIs and decision-support tools still operate as bolt-on utilities, a growing share are now being embedded directly within clinical and administrative workflows. Prior authorization processes are increasingly taking place inside the same EHR environments where providers deliver care rather than in separate systems or portals.

Major EHR platforms have started exposing native capabilities that connect directly with payer APIs, creating a more unified experience that reduces toggling between systems and reliance on proprietary web portals or fax machines. Providers have long advocated for fewer clicks to combat EHR-related click fatigue, which wastes time, increases burnout, and reduces efficiency. This tighter integration gives both payers and providers near real-time visibility into coverage requirements, documentation needs, and authorization status—without leaving the patient record.

Artificial intelligence and advanced rules engines are also maturing quickly. They’re used to prepopulate medical necessity documentation, validate it against payer criteria, and automatically route clean requests for approval. This shift from reactive to proactive automation reduces delays and minimizes manual handoffs while maintaining clinical oversight.

Recent Da Vinci Community Roundtables—information-sharing webinars where industry leaders discuss progress and lessons learned—have showcased several real-world examples of how these technologies are being implemented. Participants highlighted production-level use of CRD, DTR, and PAS transactions within provider EHRs and payer platforms, illustrating how standards are moving from theory to practice. What once required multiple back-and-forth exchanges can now, in many cases, be completed within minutes, with greater transparency into the decision process.

Taken together, these developments show meaningful progress toward workflow maturity, with provider choice between direct handling and engaging staff support. Technology is moving beyond pilots into scalable, standards-based functionality that reduces provider burden and improves payer efficiency—without losing sight of clinical nuance or compliance—while better supporting patient care needs.

Measurable Outcomes

Perhaps the most compelling evidence of progress in 2025 came from measurable results. For the first time, multiple pilots and early production implementations reported tangible improvements in turnaround times, accuracy, and user satisfaction.

Early demonstration projects such as the MultiCare and Regence pilots, conducted in 2022, helped establish the business case and technical feasibility of standards-based PA automation. The reported results and lessons learned from those efforts have continued to shape industry thinking and implementation strategies in the years since. That early groundwork helped the industry reach the level of maturity reflected in the 2025 results.

In community forums like the Da Vinci Community Roundtables and CMS-sponsored implementation updates, stakeholders have shared measurable reductions in needing to request a prior authorization and PA approval times when one is needed, with some participants noting that transactions once measured in days could often be completed within hours. The Da Vinci Trebuchet pilots provided further data on real-world CRD, DTR, and PAS transactions, showing how aligned implementations could streamline requests and reduce administrative burden. Similarly, the Humana–Providence data-sharing agreement, leveraging the Da Vinci Payer Data Exchange (PDex) implementation guide, demonstrated that standardized data exchange improves both administrative efficiency and care coordination.

Organizations are also beginning to quantify cost savings from reduced time spent gathering documentation, fewer manual reviews, and fewer denial appeals. The American Medical Association and industry organization America’s Health Insurance Plans reaffirmed their shared commitment to ensuring that licensed clinicians review all clinically based denials, a safeguard to prevent automation from eroding the quality of clinical review.

Patients are beginning to feel the difference as well. Automated workflows are reducing wait times between diagnosis and treatment, improving the overall care experience. Many payers are also reducing the list of services requiring PA, focusing attention on high-cost or high-variability cases. In parallel, the use of machine learning and artificial intelligence (AI) enables automated approvals for straightforward services, freeing staff to focus on exceptions that genuinely require review.

While this article focuses on the measurable progress achieved in 2025, even greater momentum is expected in 2026 as compliance deadlines for CMS-0057 draw closer, pilots scale into production, and payer-provider technology integrations continue to mature alongside workflow redesigns.

Together, these outcomes show that progress in prior authorization automation is no longer theoretical. The combination of policy alignment, technical maturity, and industry collaboration is producing measurable improvements in efficiency, accuracy, and patient access to timely care.

Remaining Challenges

Meaningful progress is to be celebrated; however, important challenges remain before prior authorization automation and standards-based data exchange can deliver on their full potential.

Transparency and human oversight remain essential as artificial intelligence and automated rule engines play a larger role in decision making. The industry is still determining how best to balance automation with human judgment, particularly for complex or borderline cases. Workflow redesign and refinement will take time to mature. Maintaining stakeholder trust requires that payers, providers, and patients understand when and how AI-generated recommendations are applied and when a person should intervene.

Standardizing how exceptions are handled is another ongoing hurdle. While CRD, DTR, and PAS provide a strong framework for most transactions, unique or complex scenarios still require manual steps or custom processes. Aligning these approaches across systems and organizations remains a work in progress.

Integration also continues to be uneven. Many smaller payers and provider organizations still lack modern API infrastructure and/or rely on legacy systems, creating friction that slows the adoption of automated, standards-based workflows. Delegated utilization management (UM) partners that support the PA workflow today must determine what role their systems will perform in the new API world and where to invest to support their clients. Working effectively with partners for prior authorization implementation requires clear communication, defined roles, and a shared commitment to testing to ensure the goals of automated PA are met.

Finally, questions about oversight and liability are emerging as automation expands. Policymakers and implementers alike are working through how to assign accountability when AI or automated decision support influences coverage or care recommendations. Continued collaboration will be needed to strike the right balance across innovation, regulation, and accountability.

Honorable Mentions: Other Key Health IT Areas That Advanced in 2025

While prior authorization automation saw perhaps the most visible gains, 2025 also brought notable progress across several related areas of health IT that contribute to a more connected and responsive healthcare ecosystem.

Real-Time Prescription Benefit and Coverage Transparency

Updates to the HTI-4 certification criteria encouraged broader adoption of real-time prescription benefit tools within EHRs (read our HTI-4 blog for more information). These tools are increasingly helping clinicians view patient-specific drug pricing and coverage information at the point of prescribing. Growing alignment among pharmacy benefit managers, payers, and EHR vendors is making it easier to identify cost-effective alternatives and support medication affordability discussions, although consistency and data quality remain variable across platforms.

Digital Quality Measurement (dQM)

Digital quality measurement continued to advance, supported by the National Committee for Quality Assurance’s expansion of the digital Healthcare Effectiveness Data and Information Set and the emergence of FHIR-native measurement engines from vendors such as Firely. Organizations like InterSystems, Smile Digital Health, and Clinical Architecture have improved the ingestion and normalization of clinical data, making continuous electronic quality reporting more practical. CMS and the Centers for Disease Control and Prevention (CDC) have also taken steps to reduce reliance on manual chart review, although most stakeholders agree this transition will take several more years to fully realize.

Public Health Data Infrastructure (FHIR Pipelines)

The CDC’s Public Health Data Strategy milestones for 2025–2026 helped clarify expectations for standardized reporting formats and reusable FHIR interfaces. HL7 Helios pilots continued to demonstrate multi-jurisdiction exchange patterns that could inform scalable approaches to data sharing between state and federal systems. While still in early stages, this work represents incremental but meaningful movement toward a more consistent public health data infrastructure.

FHIR as a Foundation for Payer–Provider Data Integration

FHIR adoption across payers continued to expand in 2025, supporting use cases in utilization management, care coordination, and analytics. The Da Vinci in Action Implementation Tracker reflects steady growth in active implementations, many driven by CMS-0057 requirements for provider access APIs and payer-to-payer exchange. Progress also continued around United States Core Data for Interoperability v3 and SMART 2.0 APIs for cross-enterprise data sharing, including standards for social determinants of health developed through the Gravity Project and with bulk FHIR emerging as a key enabler for population-level reporting and value-based care analytics.

These developments underscore that, while uneven in pace, standards-based data exchange is steadily becoming a shared expectation rather than a distant goal.

Conclusion: The Year Automation Began to Take Hold

2025 marked a noticeable shift in the maturity of prior authorization automation. The combination of policy alignment, technology readiness, and coordinated industry efforts translated into measurable improvements for many organizations. Still, the work is far from finished.

The progress made this year reflects the payoff of sustained collaboration between policymakers, standards developers, and implementers. The experience gained through pilots and early production deployments will help inform broader, more consistent adoption in the years ahead.

Other areas such as price transparency, digital quality measurement, public health data modernization, and payer–provider FHIR integration also moved forward, each reinforcing the same broader goal: to make health data more usable, timely, and actionable across the care continuum.

If 2025 was the year automation began to take hold, 2026 will be about turning that momentum into durable, scalable progress.

At POCP, we work closely with stakeholders to build strategic, standards-based roadmaps that make prior authorization automation achievable and sustainable investments that can be leveraged. Our team also supports multi-stakeholder initiatives, both national and state-level, that are tackling prior authorization friction at its source by aligning policy, technology, and workflow improvements. If your organization needs an objective partner to assess internal capabilities, identify gaps, and develop clear requirements for technology partners or strategic investment priorities, contact us to set up a discussion.