Prior Authorization Automation

by Surescripts  · Based in United States → — Automating medication prior authorizations for faster patient access and reduced administrative burden.
Family Medicine Internal Medicine Pediatrics
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Overview

Surescripts’ Prior Authorization Automation is a solution designed to streamline and accelerate the medication prior authorization process. It focuses on automating the retrieval of patient information directly from the Electronic Health Record (EHR) and securely sending it to the Pharmacy Benefit Manager (PBM) with minimal intervention required from healthcare providers. This intelligent automation aims to reduce the significant administrative burden associated with manual prior authorization workflows, minimize treatment delays, and improve patient access to necessary medications. The system matches clinical data with determination criteria to facilitate clinically appropriate decisions as quickly as possible, often leading to near-instantaneous approvals when requirements are met.

Reviewed by Pouyan Golshani, MD — Interventional Radiologist

Key Features

  • Automated retrieval of patient clinical data from EHRs
  • Automatic submission of data to PBMs for approval
  • Matching clinical data with determination criteria for rapid decisions
  • Real-time detection of new prescriptions for immediate initiation of PA process
  • Integration with existing EHR and PBM workflows
  • Minimal to no provider action required for many requests
  • Faster median approval times (e.g., 22 seconds for in-scope medications)
  • Reduced appeals (e.g., 88% fewer)
  • Fewer denials due to lack of information (e.g., 68% fewer)
  • Elimination of manual administrative tasks

Use Cases

  • Automating medication prior authorizations for prescribers
  • Streamlining prior authorization workflows for health systems
  • Facilitating faster medication access for patients
  • Reducing administrative burden for EHR vendors and PBMs
  • Improving efficiency in pharmacy operations
  • Enhancing care coordination by reducing treatment delays

What Physicians Need to Know

Payer Coverage Scope
Primarily focuses on medication prior authorizations (pharmacy benefit PAs). It supports over 50 medication types across seven disease areas.
Denial Rate Reduction Data
Achieved 68% fewer denials due to lack of information in pilot programs.
Auto-Appeal Capability
Demonstrated an 88% reduction in appeals for requests processed with Prior Authorization Automation. The system automates approvals, but denials are never made automatically; providers are prompted to complete a prior authorization request if not instantly approved.
CPT/ICD-10 Code Suggestion
The automation focuses on retrieving clinical data from the EHR to match determination criteria. While accurate ICD-10 and CPT/HCPCS coding are essential for prior authorizations, the tool does not explicitly offer automated code suggestion as a feature.
Real-Time Eligibility Check
Integrates with Surescripts' Eligibility product to bring real-time prescription benefit coverage information into the prescribing workflow, including automatic eligibility checks and primary coverage identification. The Prior Authorization Portal also offers patient eligibility verification tools.
RCM System Integration
Deeply integrates with Electronic Health Record (EHR) systems, allowing the automation to be triggered within existing e-prescribing workflows and automatically pull patient data. This streamlines the prior authorization process, indirectly impacting the revenue cycle by reducing administrative burden, denials, and appeals.
Prior Auth Turnaround Time
Achieves a median approval time of 18-22 seconds for automated requests. Pilot programs showed turnaround times plummeting from 8.5 hours to under 30 seconds.
Documentation Auto-Attachment
Automatically retrieves required clinical information from the patient's EHR and sends it to the Pharmacy Benefit Manager (PBM) for approval, often without requiring provider action. This includes populating question sets and gathering additional clinical information from sources like clinical notes.
Claim Status Tracking
The Surescripts portal provides real-time tracking capabilities for submitted authorization requests, with status indicators such as Submitted, Pending, Approved, and Denied, accessible within the provider's workflow.
Physician Tip

Leverage the seamless EHR integration to allow the system to proactively initiate prior authorizations and automatically retrieve clinical data. Understand that while the system excels at automating approvals, manual intervention will still be required for denied requests. Utilize the real-time tracking features within the Surescripts portal or integrated EHR to monitor the status of all submitted prior authorizations. Remember that this tool is specifically designed for medication prior authorizations, so separate processes may be needed for other types of authorizations.

Surescripts Prior Authorization Automation is deeply embedded within the Surescripts Network Alliance, connecting virtually all EHR vendors, pharmacy benefit managers (PBMs), pharmacies, and providers. It integrates directly into existing e-prescribing and EHR workflows, enabling automatic data retrieval and submission. This robust network facilitates seamless communication and intelligence sharing across the healthcare ecosystem.

Details

Category Prior Authorization
Pricing Contact sales — N/A
DeploymentIntegrated within EHR workflows
Compliance
BAA AvailableUnknown AI-estimated
HIPAA CompliantUnknown AI-estimated
FDA Status Not applicable AI-estimated — Not applicable for this type of administrative software.
Integrations
EHR Not specified
Specialties Family Medicine, Internal Medicine, Pediatrics

What the Web Says

Surescripts' Prior Authorization Automation aims to streamline the traditionally burdensome prior authorization process by integrating automated workflows directly into electronic health records (EHRs). This system automatically retrieves necessary clinical data from the patient's EHR and transmits it to the pharmacy benefit manager (PBM), often leading to approvals in seconds without human intervention. The goal is to reduce administrative burdens, accelerate approval times, and enhance patient care by minimizing delays in medication access.

Overall: Mixed

Strengths

  • Significantly reduces approval times, with a median approval time of 18 seconds for eligible requests.
  • Decreases administrative burden for healthcare providers and staff, allowing them to focus more on patient care.
  • Improves patient outcomes by minimizing delays in medication access and reducing prescription abandonment rates.
  • Integrates seamlessly with existing EHR systems, enabling prior authorization to be handled within the e-prescribing workflow.
  • Reduces denials due to lack of information and lowers the rate of appeals.
  • Offers a free, web-based portal for prescribers to submit and manage requests even if their EHR doesn't support integrated ePA.

Limitations

  • Physicians express concern that the use of AI in prior authorization by insurers may lead to increased denials and override medical judgment.
  • Some automated systems, including Surescripts, are not AI-based, which may be a point of confusion or a limitation for those seeking AI-native solutions.
  • The system may not always link refills correctly, leading to automated refill requests for medications already sent.
  • The effectiveness and benefits are currently for a limited number of therapeutic areas, though Surescripts plans to expand.
  • While automation aims to reduce staff time, some users on Reddit express concerns about job displacement for office staff.
  • The market for automated prior authorization software is crowded, and it can be challenging to differentiate true automation from repackaged legacy workflows.

Based on reviews from: Gartner Peer Insights, G2, American Medical Association (AMA), Medical Economics, Reddit, Surescripts (official website, case studies, data briefs), Forbes Councils, Insight Health, Managed Healthcare Executive, Business Wire, HIT Consultant

Last updated: 2026-07-22

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Press & Coverage

Surescripts
Surescripts Unveils Innovative Prior Authorization Automation Technology
Surescripts launched its Prior Authorization Automation technology, designed to streamline the prior authorization process and reduce administrative burdens for healthcare providers and payers. Pilot programs showed significant reductions in appeals and denials, with many approvals completed in under 30 seconds.
2025-02
Surescripts
A Leap Towards Efficiency with Prior Authorization Automation - Surescripts
This article highlights the success of Surescripts' Prior Authorization Automation, noting a median turnaround time plummeting from 8.5 hours to under 30 seconds in a pilot with Optum Rx and Cleveland Clinic. It emphasizes the collaborative effort across the Surescripts Network Alliance in achieving these efficiencies.
2025-04
Business Wire
Surescripts Expands Prior Authorization Automation, Enabling 50% More Prescribers Nationwide to Improve Medication Access for Patients in 2026 - Business Wire
Surescripts announced a significant expansion of its Prior Authorization Automation solution, reaching 68,000 prescribers across 42 health systems with an expected 119,000 more in 2026. The solution boasts an 18-second median approval time and a 34% automated approval rate for in-scope medications.
2026-05
Managed Healthcare Executive
Automating prior authorization without AI | Managed Healthcare Executive
This article discusses Surescripts' prior authorization automation, highlighting its integration with a real-time prescription benefit tool and its deployment across 20 health systems. The system pulls clinical data from EHRs for instant authorization decisions, reducing prescriber abandonment rates from 22% to 4%.
2026-04
Surescripts
Prior Authorization Automation | Surescripts
Surescripts' Prior Authorization Automation aims to match clinical data with determination criteria for rapid decisions, often without human intervention. The system retrieves information from EHRs and sends it to PBMs, resulting in a median approval time of 18 seconds.
2026-07
Surescripts
In the News: How a New CMS Rule Could Change Prior Authorization - Surescripts
This article discusses a proposed CMS rule (CMS-0062-P) that could standardize electronic prior authorization for prescriptions under federally funded health plans. Surescripts CEO Frank Harvey argues that the existing interoperability foundation can facilitate authorization decisions in seconds.
2026-07
Surescripts
Break the Bottleneck on Medication Prior Authorization - Surescripts
Surescripts highlights the expansion of prior authorization automation, noting that CVS Caremark has adopted the technology for select specialty medications, achieving approvals in as little as 22 seconds. The article emphasizes the reduction in administrative burden and faster patient access to care.
2026-03
Surescripts
4 Ways to Capitalize on the Momentum Behind the Proposed CMS Rule - Surescripts
This piece advises healthcare organizations to integrate standards-compliant tools and invest in advanced prior authorization solutions to prepare for the proposed CMS rule. It suggests that automated systems can check formulary requirements and submit documentation in real-time, accelerating patient access to medications.
2026-07

Videos

Product demos, reviews, and walkthroughs for Prior Authorization Automation.

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Frequently Asked Questions

AI-powered prior authorization systems integrate directly with Electronic Health Record (EHR) systems to detect when a prior authorization is required for a service or medication. The AI then extracts relevant clinical data from the patient's chart, pre-fills the necessary forms, and submits the request electronically to the payer. This automation significantly reduces manual administrative tasks, tracks the request status, and notifies the office upon approval, streamlining the entire process.
AI solutions for prior authorization must be purpose-built for healthcare to ensure HIPAA compliance, incorporating robust data encryption, role-based access controls, and comprehensive audit logging. It is critical to establish Business Associate Agreements (BAAs) with any third-party AI vendors to safeguard Protected Health Information (PHI). Additionally, staff training is essential to ensure they only use approved, HIPAA-compliant AI tools and avoid inputting PHI into general consumer AI systems.
AI can enhance accuracy by identifying incomplete submissions and ensuring requests align with payer requirements, which can help reduce denial rates. However, concerns exist regarding AI potentially exacerbating existing flaws in prior authorization processes and leading to wrongful denials if human oversight is insufficient. For complex medical cases or those requiring nuanced clinical judgment, human review remains crucial, as AI's effectiveness can be limited by policy variations and the need for expert interpretation.
Implementation costs for AI-driven prior authorization solutions can vary significantly, ranging from approximately $10,000 to $50,000 for smaller-scale projects to over $300,000 for extensive enterprise-level integrations with EHRs. Beyond initial setup, ongoing monthly operating costs include expenses for inference compute power, HIPAA-compliant cloud infrastructure, continuous compliance monitoring, and vendor support. While some platforms like CoverMyMeds offer free access for providers, others utilize an enterprise SaaS model, necessitating direct quotes from vendors.
Alternatives to AI-driven automation include traditional manual prior authorization processes, basic electronic prior authorization (ePA) systems, and integrated modules within existing EHR or practice management software. Manual processes are highly labor-intensive and prone to delays, while basic ePA systems streamline submission but often lack AI's advanced capabilities for clinical evidence extraction and intelligent form pre-filling. These alternatives might be more suitable for practices with very low prior authorization volumes, limited budgets, or those preferring less technologically complex solutions.
Most AI prior authorization solutions are designed for deep integration with existing EHR systems, frequently leveraging Fast Healthcare Interoperability Resources (FHIR) standards and APIs. This integration enables the AI to directly access and utilize relevant patient data from the EHR, operating seamlessly within the current clinical workflow. Before implementation, it is crucial for practices to verify their specific EHR system's compatibility with the vendor's integration list to ensure a smooth setup.
Current limitations of AI in prior authorization include the potential for 'black box' decisions that lack transparency, a limited impact on highly complex medical cases, and the risk of perpetuating undesirable payer practices if AI models are trained on historical denial patterns. Physicians should anticipate manual intervention for complex care situations, cases requiring nuanced clinical judgment, or when AI systems flag requests for a deeper human review. Human oversight remains critical to validate AI-driven recommendations and ensure ethical, patient-centric care.

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Suggest an Edit → | Last Verified: 2026-04-22 | First Added: 2026-04-22
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