How Prior Authorization Supports Safe, High-Quality Care and Lowers Healthcare Costs
Key Highlights:
- Prior authorization uses evidence-based clinical guidelines to ensure that health plans cover appropriate non-emergency care.
- Elevance Health has joined AHIP and other leading health plans to publicly commit to a set of actions that streamline, simplify, and standardize prior authorization.
- These actions include helping care providers adopt secure data exchange platforms, removing prior authorization requirements for several hundred services, honoring previously authorized care when patients move from one health plan to another, and speeding turnaround times.
Prior authorization has helped for decades to ensure people receive the right care, safely, at the right time and in the right setting. It uses evidence-based clinical guidelines to ensure that health plans cover appropriate non-emergency care.
“Prior authorization applies to non-emergency services and for only a small share of care — about 3% of claims at Elevance Health-affiliated plans,” said Dr. Catherine Gaffigan, president of the Health Solutions division at Elevance Health.
Employers, individuals, and government entities look to health plans like ours to manage the administrative work of health insurance and related services. Reviewing medical procedures, services, and medications for appropriate use through prior authorization is a fundamental piece of that work. We continually seek ways to streamline prior authorization’s administrative steps while preserving the ability to protect patient safety and help keep healthcare costs under control.
Elevance Health joined AHIP and other leading health plans in June 2025 to publicly commit to a set of actions that streamline, simplify, and standardize prior authorization. These actions aim to help all consumers get faster, more seamless access to care while reducing the administrative burden on care providers.
Ensuring Safe, Coordinated, and Evidence-Based Care
Prior authorization supports patient safety and quality care by helping ensure that recommended treatments and medications are appropriate for a patient’s specific health needs and meet evidence-based clinical guidelines. It promotes care coordination, particularly when a patient receives treatment from multiple providers, helping ensure care is consistent and informed across the care team. These steps — from helping to avoid negative medication interactions to ensuring that non-invasive treatments like physical therapy are tried before considering surgery — put safeguards in place to make sure patients are getting safe, evidence-based care.
Promoting Cost-Effective, Evidence-Based Treatment Decisions
Prior authorization helps ensure there is not another more affordable treatment or medication that is equally effective; this practice helps reduce costs for patients. It can also contribute to lower premiums for everyone by preventing and reducing billions of dollars in waste, fraud, and abuse.
In some situations, health plan physicians help support a patient’s care provider to make sure the patient gets the right care at the right time. For example, when a physician requested authorization for a partial knee replacement, our medical reviewer advised the physician that our clinical guideline would cover a total replacement. This was more appropriate and more likely to ensure a positive outcome, and the patient received a total knee replacement.
Dedicated to Streamlining, Simplifying, and Reducing Prior Authorization
In addition to our ongoing efforts to protect patient safety and promote affordability, we made commitments alongside our industry peers to connect patients more quickly to their care and minimize administration for care providers.
“One important element of quality care is timely care,” said Dr. Omar Latif, chief medical officer for the Health Solutions division at Elevance Health. “Both our internal investments and commitments alongside our peers in AHIP reinforce the importance of timeliness in PA decisions.”
Standardizing electronic prior authorization
Elevance Health helps care providers adopt innovative data exchange platforms that make it possible for health plans and care providers to securely exchange real-time information about a patient’s conditions. Not only does this partnership help patients get timely care, but it also cuts down on the administrative cost and burden for both care providers and health plans. Elevance Health care provider partners have commended the efficiency and speed of processing prior authorizations, and we continue to bring more care providers into this program.
“The different systems used by health plans and care providers make interconnectivity and standardization essential,” Latif said. “We’ve created a secure bridge, our Health OS platform, that can connect otherwise incompatible health record systems and address this challenge.”
Reducing the scope of claims subject to prior authorization
We have removed prior authorization requirements for several hundred services, Latif said. While new medications and procedures continue to become available, it’s our goal to limit prior authorization requirements to those situations when they matter most.
Avoiding delays during insurance transitions
When patients move from one health plan to another while they are receiving treatment, that new plan will honor existing, previously authorized care for a 90-day transition period.
“This was previously our practice, and it will continue,” Latif said. “We are working to simplify this process so it’s more efficient than in the past.”
Improving communication
Elevance Health has restructured its member communications around prior authorization to simplify and clarify decisions and next steps. This is in addition to new training provided to staff who handle questions about prior authorization.
“Our customer service associates are available to address questions on prior authorization, and they can connect members to our clinical teams if needed,” Latif said.
Faster turnaround times
The quickest authorizations happen via digital channels. The participating plans have committed to reach 80% real-time approvals by 2027 when the prior authorization request is submitted electronically. Our care providers who use electronic prior authorization submission through our provider portals and some electronic medical records (EMRs) receive faster responses from us, as well as two-way communication with medical directors at Elevance Health-affiliated plans.
“We continue to make significant investments in technology to improve the prior authorization experience for patients and reduce the administrative work for care providers,” Latif said. “For the prior authorization requests we receive electronically, two-thirds are processed in real time.”
Medical review for requests not approved
Using the provider portal also presents cleaner and more complete authorization information leading to quicker clinical determinations. Care providers can access all authorization data in a single location and quickly check the status of any authorization, even if it was not initially submitted electronically.
In Elevance Health-affiliated plans, artificial intelligence does not automate prior authorization denials. Only licensed clinicians can make prior authorization denial decisions.
Prior authorization continues to be essential for safe, high-quality, lower-cost care. Our focus on modernizing prior authorization, embracing digital solutions, and investing in automation that seamlessly integrates into electronic health records represents a commitment toward creating a patient-centered healthcare experience that is safer, more efficient, and more accessible.
Frequently Asked Questions
How does prior authorization help in healthcare?
Prior authorization has helped for decades to ensure people receive the right care, safely, at the right time and in the right setting. It uses evidence-based clinical guidelines to ensure that health plans cover appropriate non-emergency care.
How does prior authorization help protect patient safety?
Prior authorization helps protect patient safety by ensuring the care is appropriate for a patient’s health situation and supported by evidence-based standards and clinical guidelines.
How does prior authorization help reduce costs for patients?
Prior authorization helps ensure there is not another more affordable treatment or medication that is equally effective; this practice helps reduce costs for patients. It can also contribute to lower premiums for everyone by preventing and reducing billions of dollars in waste, fraud, and abuse.