Streamlining Prior Authorization

Earlier this year, the Centers for Medicare & Medicaid Services (CMS) finalized a rule to improve the prior authorization process, with the goal of reducing delays in patient care and reducing administrative burden on providers and payers. The rule will simplify and increase access to medical, dental and vision care by streamlining prior authorization (PA) processes using technology that facilitates the electronic exchange of information. 

Though PA requirements can help reduce costs and ensure that members receive the most appropriate care, PA processes have long been a sticking point in healthcare delivery systems. However, as payers have focused on improving their member experience, in recent years some have started to limit their use of PAs. In fact, one of SKYGEN’s clients was the first in the vision industry to eliminate PAs altogether in its vision benefits plans. Read the case study.

Dental and vision payers will have work to do to comply with the requirements of the new rule, some of which take effect as early as January 1, 2026. CMS Interoperability and Prior Authorization Final Rule CMS-0057-F is likely to increase adoption of digital processes in dental and vision, a move which will benefit members, payers and providers. 

“We are excited about CMS’s commitment to advance the end-to-end prior authorization process to improve patient care and operational efficiency,” said Jesse Filo, SKYGEN VP Software Design and Development. “We embrace a future where healthcare data exchange is seamless and frictionless, and we’re working to support interoperability with modern technologies that foster a more connected healthcare ecosystem.”

Impact on SKYGEN Dental and Vision Clients

Payers affected by the new CMS Final rule include Medicare Advantage organizations, state Medicaid and Medicaid managed plans, and Children’s Health Insurance Program (CHIP) Fee-for-Service programs. These organizations will need to put API (application programming interface) technologies in place and transform processes in order to be compliant.

“SKYGEN’s compliance team has reviewed and summarized the impact of the new CMS rule on SKYGEN operations and our clients,” said David Irish, SKYGEN Director of Compliance and HIPAA Privacy Officer. “We’ve shared this information throughout SKYGEN to ensure the development work and operational changes are made to ensure compliance with the effective dates of the new rule.”

SKYGEN is dedicating resources and time on its development roadmap as we head towards January 2027 to develop the FHIR standard API for Prior Authorizations and enhance our existing Patient Access API to include prior authorizations. SKYGEN already supports a robust suite of modern APIs for interoperability with partners, clients, and vendors to connect the various stakeholders in the healthcare industry.

We will continue to offer a high level of flexibility to meet each client’s unique PA program needs, with configurability of authorization schedules customized down to the level of an individual provider. We will also continue to offer a high degree of automation with PAs that ensures efficient, consistent determination of medical necessity, including auto determination for authorizations not requiring clinical review.

Specifics of the New CMS Rule

In addition to requirements for PAs, the CMS Interoperability and Prior Authorization Final Rule CMS-0057-F includes provisions and deadlines for the Patient Access API, Provider Access API, and Payer to Payer API. Here’s a look at the upcoming PA requirements:

Prior Authorization API (by January 1, 2027)

• Requires impacted payers to implement and maintain a Prior Authorization API with a list of covered items and services, that can identify documentation requirements for PA approval, and that supports a PA request and response
• The PA API must also communicate whether the payer approves the PA request (with the date or circumstance under which the authorization ends), denies the request (and a reason for denial), or requests more information

Improving Prior Authorization Processes 

• Timeframes: Requires impacted payers to send PA decisions within 72 hours (expedited) or seven calendar days (standard)
• Provider Notice, Including Denial Reason: Beginning in 2026, requires payers to provide a specific reason for denied PAs by portal, fax, email, mail, or phone
• Prior Authorization Metrics: Requires impacted payers to publicly report certain PA metrics annually on their website, with a compliance date of January 1, 2026. The initial set of metrics must be reported by March 31, 2026.

If you’d like to learn more about ways SKYGEN dental and vision benefits administration solutions and SaaS benefits automation platform can support your compliance, please get in touch with one of our experts. If you are a current SKYGEN client, please reach out to your Client Experience Executive.