On October 21, HHS, CMS and the Department of Labor announced that five large employers had signed a statement asking the insurers and third-party administrators that run their health plans to open up electronic prior authorization to self-funded plans. The tools in question are the ones roughly 50 insurers promised to build under the voluntary prior authorization pledge they signed in June 2025. Self-funded employer plans sit outside the federal rule that requires electronic prior authorization starting January 1, 2027.
This is a request, not a mandate. The employers did not commit to cutting prior authorization in their own plans. They said they would weigh changes like that against their duties as plan fiduciaries under ERISA, plan by plan.
For specialty practices, the bigger story is the plumbing. Prior authorization is moving onto electronic rails one payer and one plan type at a time, and the first year of public denial data shows what each request is worth. On average, Medicare Advantage insurers denied 12% of standard requests in 2025. Marketplace insurers denied 18%.
Key Takeaways
Five large employers signed a federal statement on October 21, 2026, asking insurers and third-party administrators to make electronic prior authorization tools from the 2025 insurer pledge available to self-funded plans. The statement is voluntary.
The employers did not commit to reducing prior authorization in their own plans. Changes to which services need approval would be decided plan by plan.
Under CMS's Interoperability and Prior Authorization Final Rule (CMS-0057-F), Medicare Advantage, Medicaid, CHIP and federally facilitated marketplace plans must support electronic prior authorization starting January 1, 2027. Self-funded employer plans are not covered by that rule.
In KFF's review of 2025 data, insurers denied 12% (Medicare Advantage), 14% (Medicaid managed care) and 18% (ACA marketplace) of standard prior authorization requests, on average.
When Medicare Advantage denials were appealed, 67% were overturned. The rate was 47% in Medicaid managed care and 43% in the marketplace.
What did the employers actually sign?
The document is called an Employer Statement of Support, published by the Labor Department's Employee Benefits Security Administration. It has five signatories, all large U.S. companies that sponsor their own self-insured health plans. CMS has posted a contact address for other employers that want to sign on, so the list could grow.
The ask has two parts. First, the technical improvements insurers are building under the 2025 pledge, especially more efficient, transparent and interoperable electronic prior authorization. The employers say a self-funded plan would benefit automatically if it is administered on those same platforms, and they urged insurers to make the capabilities immediately available to self-insured plan sponsors.
Second, the policy changes. Removing services from prior authorization is a plan design decision, so the employers asked only that insurers offer those reforms for each plan sponsor to consider. Nothing in the statement requires any plan to approve more requests or require fewer of them.
Which plans already face an electronic prior authorization deadline?
CMS finalized its Interoperability and Prior Authorization Final Rule (CMS-0057-F) on January 17, 2024. It applies to Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid and CHIP managed care plans, and qualified health plan issuers on the federally facilitated exchanges.
Two sets of dates matter. Since January 1, 2026, Medicare Advantage, Medicaid and CHIP payers have had to decide expedited requests within 72 hours and standard requests within seven calendar days, and give a specific reason for every denial. Starting January 1, 2027, impacted payers must offer a prior authorization API, the electronic connection that lets a provider's system submit a request and get a decision back. Prescription drugs are excluded from the rule.
CMS estimated the rule would save about $15 billion over ten years. Commercial employer plans were never part of it. That is the gap this week's statement is trying to narrow.
What did insurers promise in the 2025 pledge?
On June 23, 2025, health plans covering 257 million Americans made a set of voluntary commitments covering commercial, marketplace, Medicare Advantage and Medicaid managed care plans. Read them as targets. Some have dates that have already passed, and progress is self-reported.
The pledge included a common electronic submission framework built on FHIR, operational by January 1, 2027. It promised real-time answers for at least 80% of electronic approvals that arrive with complete clinical documentation, also by 2027. Plans also committed to cutting the number of services that need approval, honoring existing approvals for 90 days when a patient changes plans, explaining decisions more clearly and keeping medical professionals on clinical denials.
Notice the condition attached to the 80% target. Real-time answers depend on the request arriving complete. Incomplete documentation will still land in a queue.
What does the first year of public denial data show?
CMS-0057-F also required impacted payers to post prior authorization metrics for 2025 by March 31, 2026. KFF analyzed the first round and published its findings on August 13, 2026. Its review covered 14 parent insurers, with results averaged across insurers and weighted by enrollment in each market.
Standard requests were denied 12% of the time in Medicare Advantage, 14% in Medicaid managed care and 18% in the ACA marketplace. Expedited denial rates ran slightly lower at 10%, 12% and 16%. Appeals tell the sharper story. Among appealed standard denials, 67% were overturned in Medicare Advantage, 47% in Medicaid managed care and 43% in the marketplace.
The data has real limits. Insurers reported percentages, not counts. Results are not broken out by service or specialty, and there are no denial reasons. Self-funded employer plans do not have to publish these numbers at all, which is one more reason this week's statement matters.
Why should specialty practices care about self-funded plans?
Because the patient in front of you rarely knows how their plan is funded, and the card usually carries the name of a big insurer either way. The Labor Department put it plainly in its background note: providers should not have to figure out a patient's plan type before choosing how to submit a prior authorization request.
Today that is exactly what happens. A Medicare Advantage patient goes through one channel. A commercial patient on the same insurer's fully insured plan may go through another. A self-funded plan administered by that insurer may follow its own rules. Orthopedic, pain management and cardiology practices, where imaging, procedures and surgery often need approval first, feel that split on every schedule.
If insurers extend their electronic tools to self-funded clients, more commercial requests could move through the same electronic workflow as Medicare Advantage and Medicaid. That is a real gain. It is also not guaranteed, and it does not change medical necessity rules.
Where do real experts and AI fit in prior authorization?
Electronic prior authorization speeds up the transport. It does not fix a weak request. A fast denial is still a denial. That is why Cosentus runs prior authorization on R+A, Real plus Artificial Intelligence.
On the AI side, Zeus AI handles volume. Its authorization agent works requests and follow-ups, and the platform connects to 18+ EHRs using FHIR R4, HL7 and X12 standards, without replacing the practice's system. On the expert side, named specialty teams handle the parts that need judgment: matching documentation to each payer's criteria, deciding which denials are worth fighting and building the appeal.
With 67% of appealed Medicare Advantage denials overturned, that second half is where recoverable revenue lives. An expert behind every AI decision. AI behind every expert.
What This Means for Your Practice
Start with the hard deadline. January 1, 2027 is about ten weeks away. Ask your EHR or practice management vendor, and your top Medicare Advantage and Medicaid payers, how electronic prior authorization requests will flow for your specialty on day one.
Next, capture plan funding at eligibility. Record whether a commercial plan is fully insured or self-funded and who administers it. Those plans may adopt electronic tools and service reductions at different times, and you will want to know which rules apply before the request goes out.
Then use the new transparency. Payers now post their own prior authorization metrics. Compare them against your denial data by payer and by service, and appeal the denials that should not stand. The 2025 overturn rates say many of them will not survive review.
Frequently Asked Questions
Talk to Cosentus
Cosentus is an AI company with 25+ years of specialty revenue cycle expertise. Our R+A model puts real authorization and denial experts behind Zeus AI, so every request goes out complete and every denial worth fighting gets fought. See how Zeus AI works at cosentus.com/zeus-ai, or talk to our team at cosentus.com/contact or +1 (877) 266-9040.
Sources
- U.S. Department of Health and Human Services, "Leading Employers Back Expansion of Electronic Prior Authorization to Self-Funded Health Plans," press release, Oct 21, 2026
- U.S. Department of Labor, EBSA, "Employer Statement of Support Encouraging TPAs to Expand the Prior Authorization Pledge to Self-Insured Plans," Oct 21, 2026
- Becker's Hospital Review, coverage of the employer prior authorization statement, Oct 21, 2026
- KFF, "Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain," Aug 13, 2026
- CMS, Interoperability and Prior Authorization Final Rule (CMS-0057-F), press release and fact sheet, Jan 17, 2024
- AHIP, health plan prior authorization commitments, June 23, 2025
- Cosentus Zeus AI, cosentus.com/zeus-ai