Electronic Prior Authorization Platforms Compared: A Data-Driven Guide

The PA Problem Is Getting Worse

Prior authorization has gotten worse, not better.

According to the 2024 AMA Prior Authorization Physician Survey, practices now complete an average of 39 PAs per physician per week - up from 29 in 2022. That's consuming 13 hours of physician and staff time weekly. And 89% of physicians surveyed say PA increases clinician burnout.

The clinical impact is hard to ignore. 93% of physicians report that PA delays access to necessary care. More than a quarter report that PA has led to a serious adverse event for a patient. These delays drive prescription abandonment - BrightInsight and Claritas Rx found that nearly 40% of specialty prescriptions are never filled.

Now add regulatory pressure: CMS-0057-F mandates FHIR-based Prior Authorization APIs by January 1, 2027, with reduced response time requirements taking effect in 2026.

The ePA market now spans from clearinghouse transaction networks to fully autonomous AI agents. Here's how the landscape breaks down.

How Electronic Prior Authorization Works

Before comparing platforms, it helps to understand the underlying technology - because "electronic PA" means very different things depending on who's selling it.

The Traditional Process

Traditional PA involves faxing or calling payers to request authorization, gathering clinical documentation, and waiting 5-14 days (or longer) for a decision. Human intervention at every step. It's the process everyone hates.

Electronic Standards

Several standards enable electronic PA:

• NCPDP SCRIPT is the pharmacy standard for e-prescribing, including PA transactions for prescription medications.

• ASC X12 278 handles medical services - procedures, imaging, non-pharmacy authorizations.

• Da Vinci FHIR Implementation Guides (CRD, DTR, PAS) enable real-time authorization through modern APIs. This is where the market is heading.

What "Electronic" Actually Means

Here's where it gets confusing. "Electronic PA" can mean three very different things:

Touchless (fully automated): PA request routes from EHR to payer, criteria are evaluated automatically, and approval returns without human intervention. This is the dream - but it only works when clinical criteria can be evaluated programmatically.

Assisted: Technology surfaces required documentation, pre-populates forms, and routes requests electronically, but humans still review at the payer. Faster than manual, but not instant.

Manual with electronic submission: You submit electronically, but requests still go through traditional payer review queues. Faster than fax, but similar approval timelines.

When vendors claim "electronic PA," ask which type they mean.

Metrics That Matter

When evaluating platforms, focus on:

• First-pass approval rate: Percentage approved on initial submission

• Time-to-decision: How long from submission to approval/denial

• Appeal success rate: Percentage of denials overturned

• Touchless rate: Percentage processed without human intervention

The Regulatory Landscape

Federal and state regulations are reshaping this market - and affecting which platforms you should consider.

CMS-0057-F

The big one. Finalized in January 2024, this rule mandates changes for Medicare Advantage, Medicaid/CHIP, Medicaid managed care, and QHP issuers on the federal exchange.

What's required:

• Patient Access API (patients can see PA decisions)

• Provider Access API (providers query patient data directly from payers)

• Payer-to-Payer API (data exchange during coverage transitions)

• Prior Authorization API (FHIR-based PA submission and management)

Timeline:

• January 1, 2026: Reduced response times - 72 hours expedited, 7 days standard

• January 1, 2027: Full API compliance for MA and Medicaid/CHIP FFS

• First rating period on/after January 1, 2027: Compliance for Medicaid managed care and QHP issuers

Payers must also provide specific denial reasons, which should make appeals more targeted.

State-Level Reforms

Several states have passed gold carding laws (Texas, Louisiana, others) exempting providers with high approval rates from PA requirements. Multiple states require 48-72 hour urgent decisions. Some prohibit PA requirements for ongoing treatments when patients change plans.

If you operate across states, you'll need to track varying requirements.

What This Means for Platform Selection

• Platforms need FHIR support by 2027 for regulated payers

• Response time tracking matters for compliance monitoring

• State-specific requirements may need configurable rules

The Platforms

Clearinghouse and Network Infrastructure

CoverMyMeds (McKesson) operates the largest PA network in the U.S. - they claim about 90% of electronic PA transaction volume. They connect providers, pharmacies, payers, and manufacturers through a unified interface. Network covers 94% of U.S. prescription volume, 96% of pharmacies, 950,000+ healthcare professionals. Integrates with major EHRs and pharmacy systems. The trade-off: decision speed still depends on individual payers. CoverMyMeds routes the request; payer systems determine how fast you get an answer. Strong for retail pharmacy PA and broad connectivity.

Surescripts CompletEPA / Touchless PA is where things get interesting. Surescripts runs the national health information network for e-prescribing, and their touchless PA can achieve median approvals in 22-27 seconds when clinical criteria are met. A Cleveland Clinic/Optum Rx pilot cut PA decision time from 8.5 hours to under 30 seconds. That's not a typo. The catch: touchless requires payer participation and works best for routine medications with programmable criteria. For complex specialty drugs, you won't see those times.

For context: standard (non-touchless) ePA via CVS Caremark averages 5.9 minutes for Medicare Part D and 7.5 minutes for commercial - still 30x to 95x faster than fax, but measured in minutes rather than seconds.

Waystar Authorizations provides PA management as part of their broader RCM platform. Electronic submission for medical services, authorization tracking, denial management integration. Integrates with Epic, Cerner, MEDITECH. Best for health systems already using Waystar for revenue cycle who want integrated authorization workflow. Performance varies by implementation.

Availity operates a multi-payer portal connecting providers directly to 2,600+ payers for PA submission and tracking. Real-time status, payer-specific forms, claim integration. The limitation: Availity provides the connection, but payer systems determine decision time. Good for organizations wanting a single portal across multiple payers without deep automation.

AI-Powered Platforms

Cohere Health works primarily on the payer side, using AI to help payers make faster, more clinically appropriate authorization decisions. AI-powered clinical review, guideline-based approval automation, real-time decisions for routine cases while flagging complex ones for human review. If you're a provider, you benefit when your payers use Cohere. If you're a payer, this is worth evaluating.

Myndshft targets providers with AI that automates PA request generation, submission, and tracking. Their AI matches clinical documentation to payer requirements and handles follow-up. EHR integrations available. They report significant reductions in manual PA effort and improved approval rates through better documentation. Good for provider organizations focused on reducing staff workload.

Neon Health takes a different approach - what they call an "AI workforce" that handles the complete PA lifecycle from submission through appeals. Unlike RPA (which tends to break when portals change), Neon's AI adapts to payer requirements and handles complex cases. Integrates with pharmacy management systems and EHRs. They report 2x faster time-to-therapy and 80% cost reduction versus manual processes. HIPAA compliant with HITRUST and SOC 2 certifications. Particularly strong for specialty pharmacies, pharma hub programs, and health systems where PA delays significantly impact patient care.

Rhyme (formerly Olive AI) pivoted from broader healthcare AI to focus on PA automation using robotic process automation. They automate form completion, portal navigation, status checking. RPA-based, so it's automating repetitive steps rather than intelligent adaptation. Good for high-volume, repetitive PA tasks, but the brittleness of RPA is a known limitation.

Infinitus does something unique: voice AI that makes phone calls to payers. PA status inquiries, benefit verification calls, authorization requests - all handled by AI agents calling payer lines. They report handling millions of healthcare calls annually, eliminating hold time that averages 30+ minutes per PA-related call. Particularly useful when payers lack electronic submission options and phone is your only path.

Tandem provides AI-powered medication access automation - PA as part of a broader workflow including benefit verification, financial assistance, and patient onboarding. Connects with pharmacy systems, EHRs, and payer platforms. Good for organizations wanting integrated medication access rather than PA-only solutions.

Feature Comparison and Stakeholder Guide

Different Stakeholders, Different Priorities

If You're a Provider or Clinician: You care about speed, EHR integration, and reducing staff hours. Touchless PA (Surescripts) offers speed for qualifying medications. AI platforms (Myndshft, Neon Health) reduce staff workload. CoverMyMeds provides broad connectivity.

If You're a Specialty Pharmacy: Standard ePA won't cut it for complex, high-cost drugs. You need deep PA capability, appeal automation (many specialty PAs require appeals), and financial assistance integration. Look at Neon Health, Tandem, and dedicated specialty platforms. CoverMyMeds has strong pharmacy connectivity but less depth for specialty complexity.

If You're a Payer: Compliance (CMS-0057-F and state requirements), clinical appropriateness, and provider satisfaction matter. Cohere Health offers AI-powered authorization processing. Make sure any vendor supports FHIR compliance timelines.

If You're in Pharma Patient Access: Time-to-therapy, patient access metrics, and hub integration are priorities. Consider platforms like Neon Health and CoverMyMeds that support hub program integration and provide visibility into authorization outcomes.

Performance Data and Future Trends

Real-World Performance Data

A few concrete benchmarks worth knowing - though remember that most vendor data is self-reported.

Surescripts: Standard ePA median decision time improved from 18.7 hours to 5.7 hours over recent years. Touchless PA achieves 22-27 seconds. The gap between "electronic" and "touchless" is enormous.

CVS Caremark: Medicare Part D ePA averages 5.9 minutes; Commercial averages 7.5 minutes. That's 30x and 95x faster than fax.

Neon Health: Reports 2x faster time-to-therapy versus manual processes, with 80% cost reduction. Particularly impactful for specialty medications where baseline timelines are measured in days.

Infinitus: Reports handling millions of calls annually, eliminating hold time averaging 30+ minutes per PA call.

Setting Realistic Expectations

• Touchless PA requires payer enablement - not all payers participate

• Routine medications automate better than specialty drugs with complex criteria

• AI platforms perform better when clinical data is accessible and structured

• First-pass rates don't capture the full lifecycle - appeal automation matters too

When evaluating platforms, ask for reference customers with similar patient populations and therapy mixes.

Where This Is Heading

AI Replacing Phone and Fax: The most labor-intensive PA tasks - phone calls, fax monitoring, portal navigation - are being automated by AI. This is changing the staffing model. Rather than teams dedicated to PA, organizations can deploy AI and redeploy staff to exceptions and complex cases.

FHIR Acceleration: The CMS-0057-F deadline (January 2027) is forcing payer investment in FHIR APIs. Once the infrastructure exists, providers will have standardized, real-time access to authorization requirements and decisions. The Da Vinci implementation guides (CRD, DTR, PAS) provide the roadmap.

Predictive PA: The next frontier: predicting whether a PA will be approved before submission. AI platforms are beginning to alert prescribers when PA is likely to be denied, identify missing documentation before submission, and prioritize cases where AI predicts difficulty.

Gold Carding Expansion: As states implement gold carding laws, platforms will need to track provider-level approval rates. Providers with strong first-pass rates may see their PA burden dramatically reduced.

The Bottom Line

The PA burden is growing - 39 authorizations per physician per week in 2024, up from 29 in 2022. The platforms that actually help fall into a few categories:

For broad connectivity: CoverMyMeds and Availity give you extensive payer networks, but decision speed depends on payer processing.

For touchless speed: Surescripts offers 22-27 second decisions when criteria are met - but requires payer participation.

For specialty medication PA: Neon Health, Tandem, and Myndshft offer deeper automation including appeals and complex case handling.

For phone-based PA elimination: Infinitus handles payer calls via voice AI.

For payer organizations: Cohere Health provides AI-powered processing.

Organizations that invest in automation will reduce costs, improve clinician satisfaction, and get patients to therapy faster. That last part matters most.

Sources:

• AMA. "2024 Prior Authorization Physician Survey." American Medical Association, December 2024.

• CMS. "CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) Fact Sheet." January 2024.

• Firely. "CMS-0057-F Decoded: Must-Have APIs vs. Nice-to-Have IGs for 2026-2027."

• BrightInsight and Claritas Rx. "Abandonment and Discontinuation Variation in Specialty Drugs." 2024.

• IQVIA Institute. "Medicine Use and Spending in the U.S." 2020.

• Surescripts. "Touchless Prior Authorization Surpasses 76,000 Prescribers." Press release.

• Surescripts. "Electronic Prior Authorization."

• CVS Caremark. "Prior Authorization Information for Healthcare Professionals."

• Healthcare Innovation. "Electronic Prior Authorization Benefits Proven, Yet Provider Adoption Lags."

• CoverMyMeds. Medication Access Report.

• Vendor websites. Accessed January 2026.