Breakout: Advancing Prior Authorization Automation – State-Led Efforts in Washington and Massachusetts

The administrative burden of prior authorization (PA) has long been a pain point for providers and a barrier to timely care. Federal regulations, such as the CMS Interoperability and Prior Authorization Final Rule (CMS-0057), set the direction, and states are now implementing those mandates—adapting requirements to meet the needs of their populations and infrastructures. This panel will explore how states are operationalizing federal mandates, tailoring them into innovative, real-world solutions, with PA automation as a central example.

We’ll begin with the policy landscape, looking at the implications of federal rulemaking alongside related state-level efforts. The discussion will highlight two distinct approaches—Washington State’s legislative model and Massachusetts’s collaborative strategy through the Massachusetts Health Data Consortium (MHDC). Together, they illustrate how states are moving beyond compliance to create scalable, sustainable innovation.

In Washington State, legislation such as HB 1706 establishes strict timelines for PA determinations and requires commercial payers and managed care organizations to deploy automated, FHIR-based APIs integrated with provider EHRs. This top-down model demonstrates how mandates can be translated into enforceable frameworks that accelerate the adoption of interoperability standards.

Massachusetts showcases the power of collaboration. MHDC, a multi-stakeholder nonprofit, has convened payers, providers, and vendors to build the nation’s first statewide, FHIR-based PA and clinical data exchange system. Leveraging the New England Healthcare Exchange Network (NEHEN), this initiative is replacing fax and phone calls with real-time, automated approvals. The Massachusetts example shows how a neutral convener can translate federal expectations into shared infrastructure and community-driven innovation.

Beyond PA, the lessons extend to broader administrative simplification and data exchange. We will discuss how states are:

• Modernizing Eligibility and Enrollment: Automating Medicaid redeterminations to reduce coverage gaps and churn, especially post-PHE.

• Streamlining Provider Management: Using interoperable systems for credentialing, enrollment, and directories to cut overhead and improve accuracy.

• Advancing Health Data Exchange: Building secure, seamless sharing of clinical and claims data to support care coordination and informed decisions.

Attendees will gain practical insight into how states are pulling through federal rules in ways that fit their unique contexts, creating a blueprint that other states can adapt. This session is designed for state and federal leaders, health plans, vendors, and providers looking for strategies to drive meaningful progress in PA automation and beyond.