guide
Electronic prior authorization: what counts and the 2027 deadline
Electronic prior authorization (ePA) means sending a prior authorization request and getting the payor’s answer as data: through the payor’s portal, as an X12 278 transaction, or through a payor’s FHIR-based Prior Authorization API. Prescription drug requests use a separate standard, NCPDP SCRIPT.
Federal rules are moving payors toward the API. Under CMS-0057-F, most Medicare Advantage, Medicaid, CHIP and federal-exchange plans must run one from January 1, 2027. Until a payor’s API is live, your office saves the most by sending each request the most electronic way that payor accepts today.
At a glance
- Fully electronic medical prior authorization reached 40% of requests in 2025, up from 31% in 2023.
- A manual request costs a provider $12.88, and a fully electronic one $5.38.
- Since 2026, a Medicare Advantage denial must give a specific reason.
- Part D drug requests must use NCPDP SCRIPT 2023011 from January 1, 2028.
- Aetna, Humana and Wellcare take requests through Availity today.
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What counts as an electronic prior authorization
The CAQH Index sorts prior authorization requests into three groups: manual (phone, fax and email), portal, and fully electronic (the X12 278 transaction). Fully electronic medical requests rose from 31% in 2023 to 35% in 2024 and 40% in 2025, according to the CAQH Index 2025 Executive Report.
| Method | How the request travels | Where it fits |
|---|---|---|
| Phone, fax or email | Staff call, fax forms or email records to the payor | Manual. Phone is still the most common channel for medical services. |
| Payor portal | Staff enter the request on the payor’s website, such as Availity | Medical services, in its own group between manual and fully electronic |
| X12 278 | The practice’s system or clearinghouse sends a standard transaction | Medical services, fully electronic |
| FHIR Prior Authorization API | The practice’s system exchanges structured data with the payor’s API | Medical services, required of most public-program payors from January 1, 2027 |
| NCPDP SCRIPT | The prescriber’s EHR sends the request to the drug plan | Prescription drugs |
The January 2027 Prior Authorization API deadline
Under CMS-0057-F, Medicare Advantage organizations, Medicaid and CHIP fee-for-service programs and managed care plans, and qualified health plans on the federally facilitated exchanges must run a FHIR-based Prior Authorization API from January 1, 2027 (42 CFR 422.122). The API lists the items and services that need prior authorization, names the documentation each one needs, and returns an approval with its end date, a denial or a request for more information. Drugs are excluded.
Two parts of the rule already apply. Since January 1, 2026, a Medicare Advantage denial must give a specific reason, and plans post their prior authorization metrics each year, the first set by March 31, 2026: approval, denial and appeal-overturn rates and average and median decision times.
On the provider side, ONC’s HTI-4 final rule (July 31, 2025) adds three certification criteria for EHRs that connect to these APIs, built on the HL7 Da Vinci CRD, DTR and PAS guides. Payors are still building: the CAQH Index found 63% of medical plans developing their APIs, and 20% of providers had begun implementation.
Route every payor’s requests through Silna while the APIs arrive
Electronic prior authorization for prescription drugs
A CMS rule of June 17, 2024 (CMS-4205-F2) requires Medicare Part D electronic prior authorization and e-prescribing to use NCPDP SCRIPT version 2023011 from January 1, 2028, retiring version 2017071. Only 24% of physicians in the AMA’s 2025 prior authorization survey said their EHR offers electronic prior authorization for prescription medications. Silna’s guide to prior authorization for medication covers which reviewer handles a drug request.
What an electronic request saves
The 2024 CAQH Index put a provider’s cost for each prior authorization at:
| Method | Provider cost per request |
|---|---|
| Manual (phone, fax or email) | $12.88 |
| Portal | $8.93 |
| Fully electronic | $5.38 |
Volume is what makes the gap add up. Physicians in the AMA’s 2025 survey of 1,000 physicians reported 40 prior authorizations per physician per week and 13 hours of physician and staff time each week completing them.
Where payors accept electronic requests now
| Payor | Electronic channel | Other channels |
|---|---|---|
| Aetna | EDI, or Aetna’s provider website on Availity | Phone, using the number on the member’s ID card |
| Humana | Availity, which Humana encourages for Medicare Advantage medical requests | Interactive voice response line, 800-523-0023 |
| Wellcare (Centene) | Availity Essentials, its preferred portal | Fax or phone, depending on the service and urgency |
Channels change, so confirm a payor’s current one on its provider site before you send a request.
How Silna submits across payor portals
Silna submits prior authorization requests from one dashboard or through its API, so your staff don’t log in to each payor’s portal. It syncs with the EHR, intake system or CRM your team already works in, without an IT project.
Before a request goes out, Silna checks each document against payor- and specialty-specific requirements, such as signatures, credentials and dates, to catch problems before they become denials. G2 reviewers rate Silna 4.8 out of 5 across 66 verified reviews.
Map each of your payors to its fastest channel with Silna
Key terms
- Electronic prior authorization (ePA)
- A prior authorization request sent and answered as data through a payor portal, an X12 278 transaction or a Prior Authorization API, instead of by phone, fax or email.
- X12 278
- The HIPAA standard electronic transaction for requesting prior authorization and receiving the payor’s response.
- Prior Authorization API
- The FHIR-based interface CMS-0057-F requires most public-program payors to run from January 1, 2027.
- Da Vinci CRD, DTR and PAS
- HL7 guides for finding a payor’s coverage requirements, completing its documentation and submitting the request, which ONC’s HTI-4 certification criteria build on.
- NCPDP SCRIPT
- The standard for electronic prescribing and drug prior authorization. Part D requires version 2023011 from January 1, 2028.
Frequently Asked Questions
Can a practice send prior authorizations electronically today?
Yes, through a payor’s portal or an X12 278 connection where the payor accepts one. A payor’s Prior Authorization API adds another route once it is live, by January 1, 2027 for most public-program payors.
Is a payor portal electronic prior authorization?
Partly. The CAQH Index puts portal requests in their own group, between manual and fully electronic, at $8.93 each for a provider against $5.38 for a fully electronic request.
Does CMS-0057-F change decision times?
Yes. Since January 1, 2026, Medicare Advantage plans and Medicaid and CHIP programs must decide urgent requests within 72 hours and standard requests within 7 calendar days. Drug requests are excluded.
When does Part D need the new NCPDP standard?
From January 1, 2028, when NCPDP SCRIPT version 2023011 replaces version 2017071.
This article is general educational information and does not give medical, legal or insurance advice. Payor channels and federal deadlines change, so check the current rule and the payor’s provider site before you rely on them.
About the author
Jeffrey Morelli
Jeffrey Morelli is the Co-Founder and CEO of Silna Health, the first Care Readiness Platform built to remove the administrative barriers that delay care. Silna automates benefit checks, eligibility, and prior authorizations across 1,000+ payors, and is backed by $27M from Accel and Bain Capital Ventures. Before Silna, Jeff spent a decade in San Francisco building and scaling products for highly regulated industries, including leading go-to-market at Truework (Series C, acquired by Checkr).
Last updated: October 30, 2026.