The healthcare industry is making significant progress on electronic prior authorization. Standards are maturing, federal requirements are speeding up adoption and health plans are investing in interoperability infrastructure.
But there's something many organizations are reluctant to admit: electronic prior authorization won't eliminate fax.
It gives providers a better option. It doesn't take the old one away.
For plenty of providers, fax is still a part of the daily routine. That means modernizing prior authorization isn't about flipping a switch from manual to digital. For payers, it's about running a hybrid environment where both will coexist for years to come.
Federal rules require payers to implement prior authorization application programming interfaces (APIs) by January 1, 2027. Cotiviti’s FHIR gateway helps payers meet that requirement, but compliance is only part of the picture. What the rules don’t do is require every provider to use them.
And think about who’s on the other end of that fax. Plenty of practices, especially smaller and independent ones, are working with lean staff and limited technology resources, and fax fits the workflows they have today. Until electronic submission is the easiest and lowest cost option for every provider, fax isn’t going anywhere.
That leaves payers running two intake processes side by side. Electronic requests show up as structured, machine-readable data. Faxed requests show up as documents that someone has to read, interpret, and key into other systems before a clinical reviewer can begin.
So, the hard part isn’t implementing APIs. It’s dealing with all the prior authorization information that keeps arriving outside of them.
That's an operational challenge, and it needs an operational answer.
When information enters the system through different channels, it tends to take different routes. And those routes don't all end up in the same place.
Take manual data entry. It's slow, and every keystroke is a chance for error. Then there's the missing information, which often doesn't surface until a request is already in the workflow. That's when the follow-up calls start, the resubmissions pile up and delays creep in that didn't need to happen. Meanwhile, the patient waiting on the approval feels every one of those delays.
Fax isn't really the villain here. The real problem is the friction that comes from information arriving in different formats and needing different handling before anyone can act on it.
Healthcare can do better. Before a request ever reaches review, it should already be complete, accurate and ready to act on.
It's tempting to treat fax as a transitional problem that will solve itself. We don't think that's a safe bet.
Healthcare will continue to operate across a mix of legacy and modern data exchange channels for years, and payers need infrastructure that works across all of them.
That's how we think about interoperability at Cotiviti.
Rather than requiring every participant in the healthcare ecosystem to work the same way, the infrastructure should absorb the differences. The goal isn't uniformity. It's helping information arrive consistent, structured and usable regardless of the channel used.
In other words, organizations shouldn't have to wait for every fax machine to disappear before they can modernize the prior authorization process.
That's the thinking behind Fax-to-FHIR, a new functionality built into Cotiviti's interoperability solution. It applies AI and automation to the channel that's hardest to modernize, and it works in three steps:
Fax-to-FHIR combines AI-driven extraction with validation controls designed to identify incomplete or ambiguous information before a request moves downstream, and teams can review flagged cases and low-confidence fields. Each organization decides how much human oversight it wants, based on its own policies and risk tolerance.
Once the information is structured, requests can be routed to utilization management, medical policy and clinical review systems, just like electronic submissions.
The result is a much more coordinated intake process. Providers can keep submitting information the way they do today, while health plans receive more complete, standardized data at the point of intake.
The goal isn't to prolong fax. It's to stop fax from becoming a bottleneck.
Healthcare organizations shouldn't have to choose between supporting the realities of today's operating environment and preparing for a more digital future. They need infrastructure that works across both.
Rather than replacing payer APIs, Fax-to-FHIR helps ensure information submitted via fax can enter the same digital workflows and decisioning processes as electronically submitted requests.
When faxed information becomes structured, usable data the moment it enters the system, payers can stop chasing paperwork and start making decisions. That's a better experience for providers, payer teams and, most of all, the patients waiting for care.