Before Buying Another Prior Authorization Tool

October 12, 2026 | The Psychiatric Record | Practice Operations

The next prior authorization proposal may arrive with an attractive promise: fewer portals, less copying, faster responses, and a practice ready for 2027.

Before comparing prices, test that promise against a specific kind of request your staff handle.

Does the product handle the prescription requests that interrupt your psychiatric practice's day? Does it connect to the particular payer products you work with? Will the response return to the software your staff already use, or will they have another place to check?

Those questions determine what the practice is buying. A demonstration can look efficient while leaving its most consequential work outside the demonstrated process.

CMS's electronic prior authorization initiatives give practices a reason to ask these questions now. They also make precision necessary: payer requirements, drug requests, existing capabilities, and proposed changes cannot be treated as one universal 2027 deadline.

The CMS Interoperability and Prior Authorization final rule, CMS-0057-F, establishes a framework for specified impacted payers to support electronic exchange. Its API development and enhancement requirements generally begin in 2027, with exact compliance dates varying by payer type. An API is a software connection through which systems exchange information.

CMS describes a Prior Authorization API that can identify coverage and documentation requirements, support a request and response, and communicate an approval, a denial with a specific reason, or a request for more information. Approval information includes when or under what circumstances the authorization ends.

That is a useful basis for a demonstration. Can the practice identify what is needed, submit the request, receive the payer's response, and see what action remains?

The request's scope matters just as much as the connection. CMS identifies a defined group of impacted payers, including Medicare Advantage organizations, specified Medicaid and CHIP programs and managed care plans, and qualified health plan issuers on the federally facilitated exchanges. The framework should not be read as a statement that every insurance product will provide the same connection on the same date.

A psychiatric-practice demonstration could compare a TMS request with a long-acting injectable request. Treat these as test examples: have the vendor identify whether authorization is needed for that payer product and which benefit and submission route apply.

For a psychiatric practice, the drug boundary is especially relevant. The 2024 rule's prior authorization provisions concern non-drug items and services. They exclude drugs, including injectables administered in the office and covered under a medical benefit.

If prescription prior authorizations are the work you want to improve, a demonstration of a non-drug service authorization does not establish that the product handles those prescriptions. Ask the vendor to identify the request type, benefit, payer product, and supported submission route.

The exclusion of drugs from the 2024 framework does not mean electronic medication authorization has no existing requirements. CMS identifies existing requirements for Medicare Part D sponsors, and its current provider-readiness guidance separately advises asking the EHR vendor about support for Part D prescription-drug prior authorization.

CMS has also proposed expanding electronic prior authorization for drugs through CMS-0062-P. Its April 2026 fact sheet distinguishes drugs covered under a medical benefit from those covered under a pharmacy benefit. The current CMS project page, reviewed for this article, continues to describe that drug-prior-authorization expansion as proposed.

A practice can prepare for that direction without presenting proposed implementation dates as current obligations. When a sales presentation invokes a CMS rule, ask which provision it means, what its present status is, and which of your requests it reaches.

The distinction is operational. A product might support a current Part D workflow, a non-drug service connection, a future drug capability, or some combination. Ask the vendor to label each capability as available in your system, being tested, or planned. A roadmap is useful information for planning; the current workflow still needs a demonstration.

CMS's provider guidance recommends talking with the EHR vendor about its implementation timeline, integration capabilities, certification for the necessary functionality, needed upgrades or additional modules, testing, training, and technical support. It also encourages testing with vendor and payer partners.

Start there before assuming a separate product is necessary.

Ask what is supported in the version your practice actually runs. A feature available elsewhere in a vendor's product family may require an upgrade, a new module, configuration, or a payer connection your practice does not yet have. The answer should identify the work and cost involved, rather than simply repeat that the company supports electronic prior authorization.

For practices that report the MIPS Promoting Interoperability category, reporting support is another purchasing question. CMS-0057-F finalized an Electronic Prior Authorization measure beginning with the CY 2027 performance period. To satisfy it, a MIPS eligible clinician must attest "yes" to requesting prior authorization electronically through a payer's Prior Authorization API, using data from certified electronic health record technology (CEHRT), for at least one non-drug item or service ordered during the performance period, or claim an applicable exclusion. Under that finalized rule, a "no" or a missing response without an applicable exclusion results in a zero score for the Promoting Interoperability category.

The finalized exclusions cover clinicians who order no non-drug items or services requiring prior authorization during the performance period, and clinicians who order such items or services only from payers without a Prior Authorization API meeting the rule's requirements. Check the practice's actual orders and payer connections before treating this measure as a reason to buy.

CMS's July 2026 physician fee schedule proposal would make that measure optional for bonus credit in CY 2027 and required from CY 2028. It also proposes a new prescription-drug electronic prior authorization measure required from CY 2028 and changes to certification requirements. These are proposed changes, not a new universal deadline for psychiatric practices.

Ask the vendor which module supplies the prior authorization function, what its certification status is, and how the configuration connects to your certified EHR technology and supports your applicable reporting requirements. Distinguish certification available now from work planned for proposed requirements. An electronic submission alone does not demonstrate that support. Confirm your practice's reporting obligations and any exclusions, and recheck the rule's status before implementation.

Then follow the proposed workflow from beginning to end. Where are the documentation requirements displayed? What information can be populated from the existing record? What must staff still enter? Where do they see that the request was received? Where does a request for additional information appear? Where is the payer's determination retained?

These are practical questions drawn from the functions CMS describes. They are not a technical certification test. A practice need not become an interoperability developer to ask for a clear demonstration of the work its staff will perform.

CMS describes reducing reliance on manual, portal-based, and fax workflows as an intended benefit of integrated electronic prior authorization. That does not establish how much time a particular product will save your practice.

A small pilot can make the purchasing conversation more concrete. Use approved test cases to walk through a routine submission, missing information, a denial, and a request that the connection does not support. Include the staff who will do the work.

Record which steps happen in the existing system, which move elsewhere, and which still require manual entry or checking. A useful comparison follows the whole request, including additional-information cycles, rather than ending when the initial submission succeeds.

If the practice wants to evaluate time savings, define the comparison before the pilot. Compare similar request types and include setup, training, exception handling, and repeat work. State which requests the pilot covered. Do not let success with one payer or request category become a claim about the entire authorization workload.

The product may still be worthwhile if it covers only part of the work. The purchasing decision becomes clearer when that part is named and measured.

Our earlier medication-access article examined ownership of unresolved requests. This question comes before selecting the technology: which steps will the product support, and which will the practice continue to perform through another route?

For the next vendor conversation, bring a short list:

These are editorial purchasing prompts, not a validated instrument or a compliance checklist. The applicable rules, contracts, technical requirements, and local workflow still need their own review.

The useful demonstration ends with a specific statement: this capability supports these requests, for these payer products, in this version of our system, with these remaining steps. That is a firmer basis for a purchase than a general promise that prior authorization is going electronic.

Source note: Sources reviewed October 12, 2026. Purchasing questions and pilot suggestions are editorial applications of CMS guidance. This article does not report measured savings, certify a product, or determine an individual practice's compliance obligations. The drug-expansion proposal is discussed specifically; this article does not claim that every health-IT provision associated with that rulemaking remains unfinalized. The finalized MIPS measure and proposed changes to it are separate from payer implementation dates. Reporting applicability and exclusions require practice-specific review.

Educational Disclaimer: The Psychiatric Record provides general educational information for psychiatric and mental-health professionals. Content does not constitute medical, legal, regulatory, compliance, billing, or other professional advice; does not establish a standard of care; and is not a substitute for independent professional judgment. Appropriate assessment and treatment depend on the individual, setting, and current authoritative guidance. Patients should coordinate treatment decisions with their treating clinicians. For practice-operations topics, requirements may vary by jurisdiction, program, payer, contract, and circumstance. Verify current authoritative sources and obtain appropriate advice for an individual practice. Nothing here endorses a vendor or guarantees authorization, payment, efficiency, or savings.