What Blue Cross is Doing to Improve Our Prior Authorization Process, Reduce Requirements and Increase Transparency

Today | 5 min read

Key Takeaways

Prior authorization is a process health insurance companies use to validate the medical necessity and appropriateness of health care services and pharmacy treatments utilizing evidence-based guidelines.
For members, it provides assurance that they are receiving quality, appropriate treatment, at the right time and the right cost.
When patients move to a new participating health plan, existing prior authorizations for benefit-equivalent, in-network services can now carry over for a 90-day transition period.
To make the prior authorization experience clearer and easier to navigate, Blue Cross introduced a centralized, real-time tracker and online tool within the member portal.

If you’ve ever been told your doctor needs to get “prior authorization” before you can receive a test, procedure or prescription, you’ve probably wondered what it is, and why it’s part of the process.

These questions you have surrounding prior authorization are the same ones the health care industry is increasingly trying to answer more transparently.

A new update from AHIP and the Blue Cross Blue Shield Association highlights an industry-wide push to simplify prior authorization, reduce how often it’s required and make the process easier to understand for patients and providers alike. The effort stems from a set of voluntary commitments announced in 2025 in partnership with the U.S. Department of Health and Human Services and the Centers for Medicare & Medicaid Services, with more improvements planned through 2027.

For Blue Cross Blue Shield of Michigan members, that broader commitment is already showing up in practical ways, especially in terms of transparency, continuity of care and faster decision-making.

What is prior authorization and why does it exist?

Prior authorization is a process health insurance companies use to validate the medical necessity and appropriateness of health care services and pharmacy treatments utilizing evidence-based guidelines.

The goal is to ensure that members receive effective, quality care at the right time. Prior authorization is important for physicians and health care providers because it helps them make informed decisions about patient care, especially in high-risk situations or treatments that can cause serious side effects. And for members, it provides assurance that they are receiving quality, appropriate treatment, at the right time and the right cost.

Despite how much attention it gets, prior authorization applies to a relatively small share of care. Each year, Blue Cross processes about 98.5 million medical and specialty pharmacy claims. Only about 2.8% of those claims go through the prior authorization process. That means most services don’t require this extra review, but when they do, it’s for added layers of safety and quality.

How health plans are working to make prior authorization less burdensome

Participating health plans have already reduced prior authorization requirements by 11% across covered markets, resulting in 6.5 million fewer prior authorizations for patients, according to the new AHIP-BCBSA update. Additionally, plans are improving how they communicate decisions and how they support patients who switch insurance coverage in the middle of treatment, which can be an especially meaningful improvement for patients managing a chronic condition or ongoing treatment plan.

Another big change is a stronger continuity-of-care commitment. When patients move to a new participating health plan, existing prior authorizations for benefit-equivalent, in-network services can now carry over for a 90-day transition period. This means if your treatment was already approved as you begin transitioning to a new health insurance provider, you don’t have to start from scratch just because your insurance changes.

How Blue Cross supports patients who change coverage by continuing care

Helping members avoid care disruption has been one of our longstanding priorities. For Medicare members, we identify people who are either new to the plan or who have switched between Blue Cross plans or products. When one of those members needs a service that requires prior authorization, the provider is asked whether that service was already approved by a previous health plan. Because members can become eligible for Medicare at different times throughout the year, this review process happens monthly.

For commercial group members, we work with account managers during coverage transitions to help make the process as smooth as possible. If a member is joining or leaving a Blue Cross plan, reports are generated to identify open authorizations, meaning approved services that may still be active as coverage changes. These reports are run before the transition happens and again after the new coverage takes effect.

For commercial members outside of the group transfer process, we also have steps in place to help reduce care interruptions. In those cases, providers are asked for information about approvals a member may have already received from another health plan. That information can then be reviewed and, when appropriate, used to honor or automatically approve existing authorizations.

Why transparency is so important and what we are doing to address it

One area that makes prior authorization so controversial is a perceived lack of communication and transparency between the insurer and the patient. People want to know why this process is necessary, what exactly is being reviewed, how long the review will take and what will happen if a test or procedure isn’t approved right away. Improving that communication is a key part of the national commitment to prior authorization reform.

Historically, the process hasn’t always been easy for members to follow. Many people have had to rely on their doctor’s office or customer service for updates, which can lead to confusion, delays and added stress. To make the experience clearer and easier to navigate, we introduced a centralized, real-time prior authorization tracker and online tool within the member portal, along with proactive email, text and push notifications. Together, these tools allow members to:

Check whether prior authorization is required
Track status updates throughout the review process in one place
Receive real-time notifications for any change in status through text, email or app push

We also gave our service teams the ability to see the same experience members see online, helping them provide faster, more accurate support.

When members can easily check their authorization status themselves, they’re less likely to call provider offices for updates. That reduces administrative burden and allows care teams to spend more time focused on patients. Greater transparency is helpful for both patients and providers, which is why we’ve worked to create a more proactive experience that makes prior authorization easier to understand and easier to manage for everyone involved.

Learn more about what Blue Cross is doing to address health care affordability at bcbsm.mibluedaily.com/affordability.

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