Prior authorisation is intended to help payers confirm medical necessity and manage healthcare costs. But when requests rely on emails, phone calls, payer portals, and manual review queues, the process itself can become a source of delay. Providers spend time gathering and resubmitting information, while payers devote resources to validating documentation, requesting clarification, and routing cases for review. According to the American Medical Association’s 2024 Prior Authorization Physician Survey, practices completed an average of 39 prior authorisation requests per physician each week, and 93% of physicians reported that prior authorisation delays access to necessary care.
Prior authorisation automation addresses this bottleneck by connecting data, documentation, rules, and workflows. The goal is to remove avoidable administrative work so requests move faster and complex cases reach qualified reviewers sooner.
Why prior authorisation is a burden
Prior authorisation plays an important role in utilisation management, but the process can be significantly improved by eliminating manual exchanges and fragmented systems.
Providers navigate requirements that vary by payer and change over time. They gather clinical documentation, enter information into payer-specific portals, respond to requests for additional evidence, and track decisions across different channels.
Payers face a different challenge. High request volumes, inconsistent documentation, and information spread across multiple systems make it difficult to validate requests efficiently. Utilisation management and intake teams spend time checking eligibility, locating missing information, and following up with providers before a case is ready for a decision.
These delays often arise not from the clinical decision itself, but from what happens around it: incomplete submissions, duplicate data entry, document retrieval, clarification requests, and manual routing.
How prior authorisation automation can reduce care delays
Automation reduces delays by removing friction at three critical points.
- Preventing incomplete submissions: A request without required information triggers clarification and resubmission. Rules-based automation can validate information, check eligibility, and identify missing fields before a request moves further.
- Automating routine administrative checks: Not every request requires the same level of review. AI-assisted intelligent document processing (IDP) or clinical natural language processing (NLP) can extract relevant information from clinical records and compare it with policy requirements, while rules engines apply criteria and route requests by complexity. Straightforward cases require fewer manual touches, while complex cases reach qualified reviewers.
- Reducing communication and status chasing: When providers switch between portals, phone calls, and email, time is lost. Integrated payer-provider workflows connecting intake, documentation, review, adjudication, and communication create a clearer path from submission to decision.
Automation should remove waiting, not replace clinical judgement. Complex, ambiguous, or higher-risk cases should remain with qualified reviewers.
What CMS interoperability rules mean for prior authorisation
CMS is accelerating the shift from fragmented prior-authorisation exchanges towards standardised electronic data exchange. Under the Centers for Medicare & Medicaid Services’ 2024 Interoperability and Prior Authorization Final Rule (CMS-0057-F), specified Medicare Advantage, Medicaid, CHIP, and Qualified Health Plan organisations must implement and maintain Fast Healthcare Interoperability Resources (FHIR)-based APIs to improve electronic data exchange and streamline prior authorisation.
According to the Centers for Medicare & Medicaid Services’ final rule, the operational impact is:
- Faster decisions: The Centers for Medicare & Medicaid Services’ final rule requires applicable payers, beginning January 1, 2026, to communicate decisions within 72 hours for expedited requests and seven calendar days for standard requests; the seven-day standard does not apply to Qualified Health Plan issuers on the Federally Facilitated Exchanges.
- More transparent denials: Payers must provide a specific reason when denying a request, making it easier for providers to understand what is missing and then resubmit or appeal.
- Standardised electronic exchange: Under the Centers for Medicare & Medicaid Services’ final rule, impacted payers generally must meet API requirements beginning January 1, 2027, including implementing a prior authorisation API that communicates covered items and services, documentation requirements, blue-colorrequests, and responses; exact compliance dates vary by payer type.
- Greater accountability: Impacted payers must publicly report selected prior-authorisation metrics annually, providing greater visibility into request volumes and outcomes.
Together, these requirements push payers towards connected workflows, reducing manual information exchange while creating an opportunity to redesign the operating model.
Building a sustainable automation model
Successful automation entails moving appropriate requests through the process faster while maintaining clinical oversight, interoperability, and regulatory compliance. Consistent with the Centers for Medicare & Medicaid Services’ Electronic Prior Authorization overview, organisations should focus on four priorities:
- Standardise intake: Convert inconsistent provider submissions into structured, usable information to reduce missing data and rework.
- Apply AI where it adds value: Use AI to classify requests, extract information, and identify evidence against policy criteria, while keeping qualified reviewers responsible for ambiguous or higher-risk decisions.
- Design for interoperability: Connect EHRs, payer systems, authorisation workflows, and communication channels using recognised standards and FHIR-based APIs to reduce duplicate data entry.
- Measure the entire journey: Track turnaround time, manual touches, clarification cycles, approval and denial patterns, provider satisfaction, cost per transaction, and patient-access indicators.
A high automation rate is not a successful outcome if requests are incorrectly denied or providers face repeated delays. The objective is faster, accurate resolution.
How can Infosys BPM help organisations with automating prior authorisation?
Infosys BPM helps healthcare organisations modernise utilisation management through process redesign, intelligent automation, clinical documentation support, and compliance-ready payer-provider workflows. By connecting these capabilities across the prior-authorisation journey, Infosys BPM can reduce manual touches and avoidable back-and-forth while enabling qualified reviewers to focus on decisions that require their expertise.
Frequently asked questions
Typically, higher-cost or higher-variation services require prior authorisation: advanced imaging, elective inpatient procedures, specialty and infusion drugs, durable medical equipment, and some behavioural health and post-acute services. The exact list is set by each payer and plan, and changes over time, which is a large part of why providers find the requirements hard to track.
Utilisation management is the broader discipline of reviewing whether care is medically necessary and appropriately delivered; prior authorisation is the specific control applied before the service happens. Concurrent review during an admission and retrospective review after the fact are the other two forms. Automating prior authorisation without addressing the wider programme just moves the delay.
Gold-carding exempts providers with consistently high approval rates from prior authorisation for specified services, on the basis that reviewing requests that are almost always approved adds cost without changing outcomes. It requires reliable provider-level performance data and a defined review cycle, which is one of the practical arguments for measuring the whole journey rather than just turnaround time.
FHIR is a healthcare data standard that defines how clinical and administrative information is structured and exchanged through APIs. CMS requires FHIR-based APIs because prior authorisation currently depends on portals, fax, and phone, with each payer implementing the process differently. A common standard lets an EHR send a request, attach documentation, and receive a decision without the provider re-entering data in a payer-specific system.
AI can classify requests, extract clinical evidence, and compare it against policy criteria. However, KFF’s 2026 review of federal and state consumer protections reports that laws in several US states prohibit AI from serving as the sole basis for certain adverse or medical-necessity determinations and require qualified human review. A safer design therefore uses automation to support approvals and routing while preserving qualified human judgement whenever a request may be denied.
