The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)–of which some provisions are set to take effect by 2026–mandates faster decision-making, improved transparency, and better data sharing throughout the prior authorization process. Combined with state-level reforms, these changes will require both health plans and benefits administrators to innovate. For benefits professionals, compliance is more than an obligation—it's an opportunity to streamline care access, reduce frustrations, and enhance the overall employee benefits experience.

Key trends benefits professionals should watch

Interoperability and compliance drive innovation. The CMS rules are designed to address inefficiencies that have historically strained relationships between health plans, providers, and patients. The focus on interoperability will push health plans to adopt intelligent solutions that align with regulatory requirements, ensuring faster approvals and fewer care disruptions. This regulatory-driven innovation creates an opening for benefits professionals to differentiate their offerings by prioritizing seamless, employee-centered benefits.
Artificial intelligence enhances administrative efficiency. Artificial intelligence (AI) is no longer an aspirational technology—it's delivering measurable improvements in the prior authorization process today. Benefits professionals should align with technology partners that leverage AI to automate tasks such as data validation, form completeness, and decision-making. This approach minimizes administrative burden, reduces errors, and ensures that employees receive timely care. For employees, these advancements translate into fewer care delays and greater satisfaction with their benefits.
Supporting evidence-based care through clinical nudges. AI-driven "clinical nudges" ensure that care recommendations align with evidence-based medical necessity policies. These real-time insights guide providers toward alternatives based on these policies, thereby reducing cost and time and improving care outcomes. Benefits professionals who embrace plans incorporating these tools will see significant improvements in employee health and plan performance.
Responsible AI for trust and transparency. AI integration must be transparent and collaborative. Benefits professionals should prioritize partnerships with carriers and technology providers committed to responsible AI—ensuring that algorithms support clinical decisions without compromising trust. This approach builds confidence among employees and ensures that automation enhances rather than detracts from the quality of care.
Data-driven insights to optimize plan design. AI-powered predictive analytics are reshaping how health care utilization trends are anticipated. For benefits teams, early insights into emerging demands—like spikes in certain procedures—enable more proactive plan adjustments. This level of foresight allows for better resource allocation, cost control, and an enhanced health care experience for employees. For example, identifying patterns in musculoskeletal care requests can guide strategic benefit adjustments to avoid bottlenecks.

Building a benefits ecosystem that works

The evolution of the prior authorization process represents a pivotal moment for benefits professionals. By embracing regulatory-driven changes and harnessing innovations in AI, benefits managers can simplify health care navigation, enhance employee experiences, and drive better health outcomes. Supporting plans that prioritize these advancements will position organizations as leaders in employee health and wellbeing.
In 2025, transforming prior authorization is about more than just operational efficiency. It's about building a benefits ecosystem wherein employees can access the care they need, when they need it, without obstacles. By championing these changes, benefits professionals can become proactive advocates for their workforce and pave the way for a healthier, more productive future.
Dr. Brian Covino, Chief Medical Officer, Cohere Health

Instant Insights /

Transforming prior authorization: What benefits professionals need to know for 2025

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