A requirement from health insurers that providers obtain approval before performing certain procedures, prescribing certain medications, or delivering certain services, confirming medical necessity and coverage before care is delivered.
What it means
Prior authorization exists to prevent unnecessary or inappropriate care, but in practice it has become one of the largest sources of administrative burden in U.S. healthcare. Providers must submit clinical documentation to payers, wait for a determination, and often appeal or provide additional information before a request is approved; a process that historically relied on fax machines, phone calls, and payer-specific portals. Recent federal rules, including CMS-0057-F, are pushing the industry toward electronic prior authorization (ePA) built on FHIR standards, with mandated turnaround times of 72 hours for expedited requests and 7 calendar days for standard requests. Ethermed automates this process end-to-end, identifying whether a service requires prior authorization, matching clinical documentation to payer-specific requirements, generating a compliant submission, and transmitting it directly to the payer, with each step traceable and auditable.
