Electronic prior auths are coming. Here’s what physicians must ask their EHR and billing vendors

Beginning Jan. 1, 2027, health plans covered by a Centers for Medicare & Medicaid Services (CMS) rule must run standardized electronic connections that transmit prior authorization requests, documentation and decisions between a physician's electronic health record (EHR) and the plan. The rule is CMS-0057-F, the Interoperability and Prior Authorization Final Rule.

The legal obligation sits with the plans. The physician's side of that connection is the practice's own EHR, prior authorization tool or billing partner. If those vendors are not ready, the plan can report compliance in January while the practice keeps faxing.

That gap now has Washington's attention. In September, American Medical Association CEO John Whyte, M.D., M.P.H., urged CMS Administrator Mehmet Oz, M.D., MBA, to keep the Jan. 1 date and not give plans broad leeway on enforcement in 2027, warning that the last mile of implementation falls to vendors "not subject to CMS oversight and enforcement." Whyte also asked CMS to give physicians clear questions to put to their EHR developers and health plans now.

What has already changed, and what changes on Jan. 1?

CMS finalized the rule in January 2024 after years of physician complaints about fax and portal prior authorization, and three parts of it are already in force. Since Jan. 1, 2026, covered plans must decide standard prior authorization requests within seven calendar days and urgent requests within 72 hours, except marketplace plans on the federal exchange, which are not subject to that requirement. Every covered plan must give a specific reason for a denial rather than a generic "not medically necessary." And plans had to post their prior authorization statistics publicly for the first time by March 31, 2026.

The Jan. 1, 2027, deadline is about the technology. Plans must run four electronic connections, called application programming interfaces (APIs). The Prior Authorization, Provider Access and Payer-to-Payer APIs are new, and the existing Patient Access API is expanded. The one that matters in the exam room is the Prior Authorization API. It tells the EHR whether a service needs authorization and what documentation the plan wants, carries the request to the plan and returns the decision or a request for more information. Whether the plan's documentation questionnaire comes back prefilled from the chart depends on your EHR, not the rule.

The rule does not require an instant answer. Plans may still route a request for clinical review within the seven-day or 72-hour clock. The electronic channel changes how the request travels, not whether a nurse reviewer reads it.

Does this apply to my patients?

Only some of them. The rule covers Medicare Advantage plans, state Medicaid and Children's Health Insurance Program fee-for-service programs, Medicaid and CHIP managed care plans, and marketplace plans sold on the federal exchange. If your state runs its own exchange, as California, New York and about 18 other states do, those plans are outside the federal rule, although your state may have its own prior authorization law that applies to them. Pediatric and ob-gyn practices with large Medicaid and CHIP panels will see the most change.

The rule does not cover employer-sponsored commercial plans, which for many independent practices are the largest share of the panel, or traditional Medicare. So in January, some prior authorizations can go electronic through the EHR while others stay on the portal, fax and phone. Ask your vendor to show, by your top 10 payers, which will be connected on Jan. 1 and which will not.

Does it cover prescription drug prior authorization?

No, and this is where vendor sales language gets loose. The 2024 final rule excludes prior authorization for drugs, including drugs administered in the office and billed to the medical benefit. A vendor that describes drug prior authorization as "covered" under CMS-0057 is ahead of the law. When a patient asks in January why a prescription is still held up, the honest answer is that drug prior authorization is not in this rule yet.

On April 10, 2026, CMS issued a separate proposal, CMS-0062-P. It would bring medical-benefit drugs into the Prior Authorization API starting Oct. 1, 2027. It would also add electronic standards for pharmacy-benefit drugs at Medicaid, CHIP and federal marketplace plans, and set faster deadlines for drug decisions. The comment period closed June 15, 2026. As of this writing there is no final rule.

Ask your vendor two separate questions. First, what does it support today for drug prior authorization, which usually runs through the e-prescribing workflow? Second, what does it plan to do if the drug rule is finalized?

What should I ask my EHR vendor?

CMS' own guidance to physicians is to confirm EHR vendor readiness, take part in testing with plans and begin electronic submission by Jan. 1, 2027. Six questions turn that into a vendor conversation.

• Which payers will be live inside my ordering workflow on Jan. 1, by name? Get plan names and dates.
• Is this in my current version and license, or an upgrade or add-on with a fee?
• Can you show me one real order going through the electronic path with one of my actual payers before January?
• When the plan's system is down, or it asks for more information, where does the request land? A good answer names a work queue with the reason and a timestamp.
• When the plan asks for documentation, does the tool pull it from the chart and attach it, or does staff copy it in by hand?
• Who is responsible when a request stalls, the EHR, the clearinghouse or the plan? Get the answer in writing.

One more question is easy to miss. The Provider Access API lets an in-network physician pull a patient's claims and prior authorization history from the plan through the EHR, unless the patient opts out. Ask whether your EHR will use it, and when.

What should I ask my prior authorization or billing vendor?

If a third-party tool or an outsourced billing company handles your prior authorizations, that partner decides, payer by payer, which channel a request takes. Find out which channel each of your top payers will use in January: the new API, a portal, fax or phone. Find out whether the status, decision and denial reason flow back into the chart, or whether staff still re-key them. If the tool automatically routes a request to fax, it is still a fax request, with none of the speed of the new channel. And ask what happens to your data and open cases if you switch vendors.

Does the rule require anything of my practice?

Not directly, but practices that report under the Merit-based Incentive Payment System (MIPS) will feel it. For those clinicians, the 2024 rule added an Electronic Prior Authorization measure to the Promoting Interoperability category beginning with the 2027 performance year: a yes-or-no attestation that the practice sent at least one request through the Prior Authorization API, or qualifies for an exclusion. In July, CMS proposed making that measure optional for 2027 and required in 2028, alongside a new drug prior authorization attestation. The final decision is expected this fall. Either way, sending at least one request in 2027 keeps you ready for 2028. Practices of 15 or fewer clinicians are automatically excused from this category, with its weight shifted to other categories, unless they choose to report it.

Will the fax machine finally go away?

No. Plans must add the electronic channel; they do not have to close the old ones. Brian Covino, M.D., chief medical officer of Cohere Health, told Medical Economics in August that some health plans, when they first become Cohere clients, still receive 100% of their prior authorization requests by fax. Commercial payers, drug requests and peer-to-peer cases will stay on the old rails for a while.

How will I know whether any of this worked?

Measure before January. Physicians told the American Medical Association in its latest survey, released May 13, 2026, that they complete an average of 40 prior authorizations a week, that the work consumes about 13 hours of physician and staff time weekly, and that 40% of physicians have staff who work exclusively on prior authorization. CMS puts the cost at roughly $34,000 and 700 hours per physician each year.

Record your own numbers now, by payer: requests per week, staff hours, days to decision, denial rate and resubmissions. In the first quarter of 2027, compare them with your baseline and with the turnaround times each plan has posted. If the gap is large, raise it with the plan's provider relations line.

The one thing a vendor can hand you today is a payer-by-payer list with dates. Ask for it this month.

Hoyt Gong is the founder of Rx Almanac (rxalmanac.com), an independent research directory of pharmaceutical and health care services vendors, and an MBA candidate at Harvard Business School. His background is in biopharma, technology and strategy.