Variation and Standardization in Prior Authorization Requirements
Authors: Zaari Jabri Aya , Asher Jacob , Sandling Jacqueline , Schulman Kevin , Scheinker David 
Published: February 2025

Importance

Prior authorization rules are neither regulated nor standardized and contribute to wasted spending, delays in care, and physician burnout.

Objective

To examine and compare the prior authorization rules of large private US insurers.

Design

This study converted prior authorization rules into a single framework; quantified variations, inconsistencies, and contradictions within and across insurers; and developed a single algorithm to reproduce and compare the prior authorization rules of all insurers.

Setting

Prior authorization rules from the providers manuals of Humana, United Healthcare, Anthem California, and Aetna.

Participants

The prior authorization rules for in-network providers and internally managed contracts were included while the rules for out-of-network providers, for determining provider network status, and for services managed by external vendors were excluded.

Results

The provider manuals cover 19,637 services and medications. Of these, Humana requires prior authorization for 3,048, United Healthcare for 2,682, Anthem California for 2,188, and Aetna for 842. To determine if PA is required, Anthem California provides a medical criteria document for each service and medication. The other insurers use six criteria for varying sets and categories of services and medications. There are 18 potential requirements to obtain prior authorization from Anthem California and a total of five across the other insurers. The manuals contain duplicated, ambiguous, and contradictory guidelines.

Conclusions

In an analysis of the provider manuals of four large US insurers, prior authorization rules differed significantly across services within each provider manual and across provider manuals. The rules were reproduced with a simple framework of 6 criteria to determine if prior authorization is required and 23 requirements to obtain prior authorization, providing an empirical example of a single standardized contract reproducing the rules of several contracts from different large health insurers. The methods presented to standardize and simplify contracts may help inform efforts to rationalize and improve the prior authorization process as well as broader efforts to reduce administrative costs and waste through standardization.

Key Points

Question

Do prior authorization rules, purportedly derived from evidence-based coverage policies, differ across large private US insurers?

Finding

Prior authorization rules differed significantly across services and across insurers with contradictions and inconsistencies. The rules were reproduced with a framework of 6 criteria to determine if prior authorization is required and 23 requirements to obtain prior authorization.

Meaning

The methods presented to reproduce the prior authorization rules of four large insurers in a single framework may help inform efforts to standardize the prior authorization process. The present approach may inform broader efforts to reduce administrative costs and waste through contract standardization.