Prior Authorization Requirements by Payer: What Every Practice Needs to Know in 2026
Prior authorization requirements vary dramatically from payer to payer -- and even from plan to plan within the same payer. A procedure that sails through approval with one insurer may require extensive documentation and weeks of waiting with another.
This guide provides a high-level overview of PA requirements for the major national payers, along with key 2026 policy changes that practices should be aware of.
UnitedHealthcare (UHC)
UnitedHealthcare is the largest commercial insurer in the United States and has one of the most extensive prior authorization programs.
Key PA requirements:
- Advanced imaging (MRI, CT, PET) requires PA for most plans
- Outpatient surgical procedures above a dollar threshold
- Specialty medications and biologics
- Genetic testing
- Durable medical equipment over a cost threshold
How to submit: UHC strongly prefers electronic submission through their provider portal (UHCProvider.com) or through Optum's electronic PA platform. Phone and fax are accepted but processed more slowly.
Typical turnaround: 3-5 business days for standard requests, 24-72 hours for urgent/expedited requests.
2026 changes to note: UHC has expanded its gold carding program, which exempts providers with high approval rates from PA requirements for certain services. Providers with a 90%+ approval rate over a 12-month period may qualify.
See full UnitedHealthcare PA details
Anthem / Elevance Health
Anthem (now Elevance Health) operates Blue Cross Blue Shield plans in 14 states and has a significant national presence.
Key PA requirements:
- Advanced imaging
- Elective inpatient admissions
- Outpatient surgery at ambulatory surgical centers
- Select specialty drugs
- Home health and DME
How to submit: Anthem uses AIM Specialty Health for imaging PA and has its own portal for other services. Electronic submission is preferred.
Typical turnaround: 2-5 business days for standard, 24 hours for urgent.
2026 changes to note: Anthem has simplified its imaging PA process through AIM, reducing the number of clinical questions required for common procedures. They have also expanded their list of procedures exempt from PA.
Aetna / CVS Health
Aetna, owned by CVS Health, has integrated pharmacy and medical benefit PA into a more unified process.
Key PA requirements:
- Advanced imaging
- Outpatient surgery
- Specialty pharmacy (managed through CVS Specialty)
- Cardiac procedures
- Spine surgery
How to submit: Aetna accepts electronic, portal, phone, and fax submissions. Their Availity integration allows real-time eligibility and PA submission.
Typical turnaround: 3-5 business days standard, 24-48 hours urgent.
2026 changes to note: Aetna has been consolidating medical and pharmacy PA into a single workflow through the CVS Health platform. This impacts practices that prescribe specialty medications.
Cigna Healthcare
Cigna has been expanding its PA requirements in recent years, particularly for high-cost imaging and surgical procedures.
Key PA requirements:
- Advanced imaging (MRI, CT, PET, nuclear medicine)
- Outpatient surgical procedures
- Specialty medications
- Physical therapy beyond an initial visit threshold
- Genetic and molecular testing
How to submit: Cigna prefers electronic submission through EviCore (their utilization management partner for many services) or through the Cigna provider portal.
Typical turnaround: 5-7 business days for standard, 24-72 hours for urgent. Cigna tends to have longer turnaround times than some competitors.
2026 changes to note: Cigna has expanded their use of EviCore for additional service categories. Practices should verify which services route through EviCore vs. Cigna directly.
Humana
Humana has a large Medicare Advantage population, which means their PA requirements often reflect CMS guidelines.
Key PA requirements:
- Advanced imaging
- Inpatient admissions
- Home health services
- DME
- Select outpatient procedures
- Post-acute care (SNF, rehab)
How to submit: Humana uses their provider portal and accepts electronic, phone, and fax submissions. They partner with CareCore National (now EviCore) for some imaging PA.
Typical turnaround: 2-5 business days standard, 24 hours urgent.
2026 changes to note: CMS finalized rules requiring Medicare Advantage plans (including Humana MA) to implement electronic prior authorization by 2026. This should significantly speed up the PA process for Humana Medicare Advantage patients.
Blue Cross Blue Shield (State Plans)
BCBS is not a single payer but a federation of independent state-based plans. PA requirements vary significantly by state.
Key PA requirements (generally):
- Advanced imaging
- Elective surgery
- Specialty medications
- DME
- Mental health services (some plans)
- Physical/occupational therapy beyond visit limits
How to submit: Varies by state plan. Most BCBS plans have their own provider portals. Some use third-party UM companies for specific service lines.
Typical turnaround: 3-7 business days depending on the state plan.
2026 changes to note: Several state BCBS plans have adopted gold carding or prior authorization exemption programs. Check with your specific state plan for eligibility.
Medicare (Traditional / Fee-for-Service)
Traditional Medicare has historically required less prior authorization than commercial payers, but this has been changing.
Key PA requirements:
- Certain DME items
- Non-emergency ambulance transport (in applicable regions)
- Certain Part B drugs
- Select outpatient services under the Prior Authorization program
- Home health services (in some MACs)
How to submit: Through the Medicare Administrative Contractor (MAC) for your region, typically via the MAC portal or fax.
Typical turnaround: 10 business days for standard, 2 business days for expedited.
2026 changes to note: CMS has finalized the Interoperability and Prior Authorization Rule, requiring Medicare Advantage plans to implement electronic PA APIs by 2026. Traditional Medicare is also expanding its prior authorization model for additional services.
Key Takeaways for 2026
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Electronic submission is becoming mandatory, not optional. Payers are increasingly requiring or strongly incentivizing electronic PA.
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Gold carding programs are expanding. Providers with high approval rates can earn exemptions from PA. Track your approval rate by payer.
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CMS rules are driving standardization. The federal push for electronic PA and interoperability is creating more consistency across Medicare Advantage plans.
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Third-party UM companies are growing. EviCore, AIM, and similar companies now manage PA for many payers. Know which services route through which UM company.
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Requirements change frequently. Payer medical policies and PA lists are updated quarterly or more often. What did not require PA last month may require it this month.
Stay Current
The most dangerous thing a practice can do is assume that last year's PA requirements still apply. Requirements change constantly.
Use our free Payer PA Contact Directory to find current phone numbers, portals, and submission methods for every major payer. And if you want to automate PA requirement checking so your team is never caught off guard, see how Greenlight can help.