Epic’s Real-Time Prior Authorization Checks Go Live at Four Health Systems

The workflow is live at Ochsner Health, Froedtert ThedaCare Health, Denver Health, and Summit Health, with UnitedHealthcare, Network Health, and Aetna among the first health plans supporting the technology.

Four US health systems, including Ochsner Health and Denver Health, are now using real-time prior authorization checks embedded in Epic’s electronic health record (EHR), allowing clinicians to determine immediately whether a medical service requires insurance authorization.

The workflow is live at Ochsner Health, Froedtert ThedaCare Health, Denver Health and Summit Health, with UnitedHealthcare, Network Health and Aetna among the first health plans supporting the technology.

Epic introduced the real-time insurance review workflow using the Coverage Requirements Discovery (CRD) API, an industry-standard application programming interface designed to allow providers to check coverage and prior authorization requirements directly within the EHR. Epic is testing the API with 16 additional payers.

The technology eliminates the need for clinicians and administrative staff to call insurers, send faxes, or re-enter information into separate payer portals to determine whether authorization is required. If prior authorization is not needed, treatment can proceed without waiting for an approval check. When authorization is required, providers can begin the process earlier.

The CRD API is part of the electronic prior authorization framework developed through the HL7 Da Vinci Project, which also includes Documentation Templates and Rules (DTR) and Prior Authorization Support (PAS) implementation guides. Together, the standards are designed to automate the process from determining requirements through submitting authorization requests.

The rollout comes ahead of a Centers for Medicare and Medicaid Services (CMS) interoperability requirement for certain health plans to support standardized, FHIR-based APIs for electronic prior authorization beginning January 1, 2027. The requirement covers Medicare Advantage, Medicaid, the Children’s Health Insurance Program, Medicaid managed care and qualified health plans.

Epic said operationalizing the standards has required coordination between payers, providers, and technology teams to integrate the workflows into existing clinical processes.

The company is also exploring artificial intelligence to further automate prior authorization. Epic plans to use AI within the provider system to interpret payer responses and review patient records to determine whether authorization requirements have been met.

CMS has separately proposed moving an electronic prior authorization measure for hospitals from an optional bonus to a mandatory requirement beginning in calendar year 2028.

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