HMN 2026: How Prior authorization rules vary widely among major commercial insurers,

A brief research report reviewed the prior authorization rules for Aetna, Humana, and UnitedHealthcare and found little consistency in their prior authorization rules. The findings highlight a fragmented system that may contribute to administrative burden for clinicians and confusion for patients. The report is published in Annals of Internal Medicine.

As part of a research program on the potential benefit of standardizing health care contracts, researchers from Stanford University and colleagues examined how prior authorization rules vary across commercial insurers and whether those rules could be organized into a single, searchable database like the ICD-10 system.

They analyzed publicly available provider manuals from Aetna, Humana, and UnitedHealthcare, reviewing thousands of procedure and service codes to determine when prior authorization was required and what information clinicians had to submit to the insurer to obtain authorization for a particular test or treatment.

Using a combination of automated review and manual checks, they built a searchable database and used it to compare insurer rules. They found that while all three insurers required prior authorization for some services, the majority of services required prior authorization from only one of the three insurers, and the criteria and documentation requirements differed widely.

The authors conclude that assembling these rules into a shared database is feasible and could improve transparency for both patients and clinicians, but the unexplained differences across insurers warrant further research on the appropriateness of this administrative barrier to patient receipt of some interventions ordered by their clinician.

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