The Fax Machine Knew What Day It Was
Every few months, a veteran in Iowa needs VA's permission again to keep seeing his chiropractor. VA's auditors had to read fax cover sheets to learn how long requests like his really wait. Starting in 2027, as each site goes live, new contracts put a deadline on the contractor who will handle them and none on VA.
Friends,
Every few months, John-Paul Sager's permission to see his chiropractor runs out.
Sager served in the Marine Corps and the Army and lives in Denver, Iowa. The pain in his back and shoulder goes back to his service. The local VA does not offer chiropractic care, so VA pays for his visits to the Vanderloo Chiropractic Clinic, about fifteen miles away in Waterloo. Then the approval lapses and he starts making phone calls, often several. "It seems like it takes entirely too long," he told KFF Health News last year. He values the VA all the same. "You just feel like you're being taken care of by your own," he said. [1]
Linda Gill sees the other half of it. She manages the clinic's office, where about a dozen veterans come through the program. VA pays about $34 a visit, which she called comparable to private insurance, and the paperwork is heavier. The clinic's leaders thought about leaving the VA program and decided to stay. Gill had a plea for the department: "After what they've done for us? Please." [1]
KFF's reporting ends at the clinic door, and so does everything Sager and Gill can see. A request for more care goes into VA, and at some point an answer comes out. On September 24 the inspector general published what happens in between. [2]
The auditors examined about 2.6 million requests for more care, filed from October 2024 through January 2026. The formal channel is VA Form 10-10172, the Request for Services, which a community provider files when a veteran needs more than the original referral covered: more visits, more time, another specialty, a procedure outside the episode VA approved. [3] I call it the second yes. VA's rule gives the department three business days to decide and to tell both the doctor and the veteran. Seventeen percent of the requests had a recorded decision notice within that window. [2]
The detail I cannot put down is how the auditors learned what the real waits were. To check the dates in VA's tracking system, they opened veterans' medical records and read the fax cover sheets. The system had one request at 7 days. The date printed on the fax said 21. It had another at 13 days, and corrected, that one took 35. In a sample of 124 requests at four facilities, the system and the fax disagreed about one time in five. [2]
In that sample, the fax machine kept better time than the tracking system.
My argument is narrow. VA should start one clock the moment a request first arrives, stop it the moment the veteran is told, and publish what it reads. Starting in 2027, as each VA site goes live, ten-year contracts put a deadline on the contractor's stretch of that trip and none on VA's. On January 1, a federal rule requires Medicare Advantage and Medicaid plans to offer the whole thing electronically.
After it leaves the clinic
At the four facilities the auditors visited, staff said most requests arrive as an electronic fax, and from there the work is done by hand. Someone has to open the fax, sort it, and type it into a tool called the Consult Toolbox before a nurse can review it. The report says requests "can remain in fax queues for up to two months" before that happens. Two facilities each had more than 1,700 waiting to be logged. At a third, managers stopped entering new requests and moved the staff to other authorization work, and by September 2025 more than 3,700 sat unentered. [2]
When a request is finally entered, a person types the date it arrived, because the tool, VHA officials told the auditors, "cannot automatically capture the actual date." The auditors found staff typing one of three things: the date the doctor signed the form, the date the fax was sent, or the date they got to it. There is "no established national procedure for verifying the correctness of receipt dates." [2] If the staff member types the day of entry, a request that sat six weeks in the queue and was decided in two days is a two-day request. My read is that the eight-day average in VA's own data is an estimate, and VA cannot presently say how far off it is.
The people doing this work are short-handed and inventive. At one facility, thirty community care nurses each kept a spreadsheet of their own to track their requests. At another, managers told staff to "close requests on the fourth day after the request was entered into the Consult Toolbox," whether or not a clinician had decided. The notification template was supposed to offer a "needs more time" option. Two staff members said it was gone, which left approval and denial. One of them chose denial and typed a comment: "still under provider review." The veteran was to be advised to follow up with primary care. The practice was still in effect in April. [2]
The inspector general had said as much before. Leigh Ann Searight, a deputy assistant inspector general, told the Senate in February that these delays "can hinder follow-up care for veterans." [4] The new audit added the count: 45 percent decided within three business days, about eight on average, and for 46 percent of requests, about 1.2 million, no record that anyone was told the answer. [2] That is the view from inside VA. From the clinic's side of the fax, it looks different.
Meanwhile, at the clinic
While the request sits, VA's guidebook tells the clinic what to do, which is nothing: "no additional veteran care should be provided or paid for" until VA sends its notice. A doctor who follows that rule waits, and so does the patient. A doctor who keeps treating is working without an authorization, and the report warns of "potentially leaving the veteran or provider liable for the cost of the care." [2]
Mental health requests waited longest among the specialties the audit broke out, ten days on average, with 68 percent late. Staff at most of the facilities the auditors visited described care delays of "sometimes more than 60 days," and the audit team sent three cases of delayed care to the inspector general's health care inspectors. [2]
Then the answer has to find its way back. A missing record is different from a missing phone call, and some of those 1.2 million doctors and veterans surely heard. But one nurse told the auditors that staff were told to "fax notifications only to providers and not to notify veterans," and VA's own web page for community providers promises a notice to the provider and does not mention the veteran. [2][3]
The provider side has stopped expecting three days. One national therapy network tells its clinicians to send renewals at least 30 days before an authorization expires, because VA "requires a minimum of 30 days to review, approve, and issue a renewed authorization." [5] Some veterans stop asking. Marcus Lewis, a Navy veteran who runs the health center in Park River, North Dakota, put it to KFF this way: "I think a lot of folks just don't want to fight the system." [1]
Half a clock
On August 27, John Figueroa, signing as Acting Under Secretary for Health, answered the audit in one sentence: "VHA concurs with the recommendations made to the Under Secretary for Health." There are six, each due in July 2027. [2] Four days later VA signed the next generation of its Community Care Network contracts with four companies. The period of performance opens January 1, 2027 and runs through 2036. [6]
I read the contract documents with the audit open beside them: the work statements, the contractor manual, the surveillance plans, and the incentive plan, as released during the competition. They are pre-award versions hosted by a third party, and the task orders could change them, so take what follows as the design on paper. [7][8][9]
The change arrives one site at a time. The contractor takes over these requests "beginning at the start of HCD," the contract's shorthand for health care delivery, and delivery starts station by station as the contracting officer accepts each one, "no sooner than 90 days from contract award." [7] A third-party index of the documents showed no medical task orders posted as of October 11. [6]
When a site does go live, the front door moves for a clinic like Gill's. The request goes into the contractor's portal and gets an identifier and a time. The contractor checks that the package is complete, reviews it against VA's medical policy, and sends VA a recommendation. For the first time there is a deadline in writing: a standard request "shall be reviewed and submitted to VA within one (1) business day of receipt of complete RFS package." An urgent one gets four hours. [7]
Then the deadlines stop. The contractor's day starts only when the package is complete, and a request sent back to the clinic for a missing document has no deadline on the return. Once the recommendation reaches VA, the work statement says "VA has the sole responsibility to make final decisions," and it sets no deadline for the decision and none for telling the veteran. The work statement has a section for exactly this subject, 8.5, "Timeliness of UM Recommendations." [7]
It times the contractor and stops.
The manual's matching section adds nothing. It is marked "RESERVED," the manual's label for any section where it has nothing to add. [8] That is half a clock, and no money rides on the half that exists. The surveillance plans' performance objectives cover network, customer service, claims, medical documentation, and value-based care, with none for these requests, and the incentive plan pays or docks on a count of adverse credit reporting tickets and on value-based network coverage. [9]
The first year is labeled "Establish Baseline." The quarterly report that would show the contractor's numbers begins twelve months after full health care delivery, which VA told the House to expect in 2028. [7][10] The access standard everyone watches starts counting "from the date the referral is approved by VA," so a veteran can wait twelve days for the second yes and four more weeks for the procedure and go into the data as a success. [7]
The documents come close. The contractor's system must record a "Request Received Date/Time" and a "Decision Date/Time" for every request, and the required list has no field for the day the veteran is told. [7] From its first day at each site, the contractor will know what day it is. VA put the contractor's deadline in a contract and left its own in a guidebook.
What switches on January 1
On the other side of American health care, the date is fixed. Starting January 1, every Medicare Advantage, Medicaid, and CHIP plan must offer an electronic interface that tells a doctor's record system what documentation an approval needs, takes the request, and returns the answer. A doctor may still fax, and the plan must have the electronic door open. Those plans have owed doctors "a specific reason" for any denial since 2026 began, and by the same January date information about the request has to be available to the patient. [11]
The clock is written down too. It "starts when an impacted payer receives a prior authorization request," a request for documents the payer never listed does not pause it, and every plan had to post its approval rate, denial rate, and average and median decision times by March 31 of this year. [12]
Put Gill's clinic in that world for a moment. Before she sends anything, her system asks the payer what the approval requires and fills in the payer's own template. The request goes as a transaction that carries its own timestamp. The answer comes back the same way, with a reason if it is no, and the patient can see it.
Three public HL7 standards built on FHIR do those steps, and insurers covering about 270 million people have pledged to answer at least 80 percent of complete electronic requests in real time by 2027. [13][14] It is a pledge, and one physician in three told the American Medical Association it will make a meaningful difference. [14]
The evidence in hand is older and less glamorous. In 2020, six health plans moved prior authorization for prescriptions and procedures onto electronic tools, and an independent evaluation of more than 40,000 transactions found the median time from request to decision fell from 18.7 hours to 5.7. Fifty-eight percent of experienced users reported sending fewer faxes. [15]
The Department of War does a version of this for its own. The TRICARE Operations Manual requires contractors to decide 90 percent of authorization requests within two business days once a request is complete, and all of them within five. That is a requirement, and I found no public data on performance against it. [16] The TRICARE contractor makes that determination itself, so its deadline covers the decision. The VA contractor's deadline covers the handoff.
VA's portal is real progress measured against a fax queue. It also moves requests on the older transaction, the X12 278, which HHS proposed in April to replace with FHIR for HIPAA covered entities. [8][13] VHA is a covered entity, so a final rule would likely reach these requests, and the solicitation for the new contracts already tells offerors to "consider FHIR as it becomes standardized." [17] VA can build this door once or twice.
The $1.7 billion objection
The best argument against all of this came from the same inspector general in June. About 25 percent of 1.4 million veterans sent to community care in a single quarter did not meet eligibility requirements, and the auditors estimated VA could have avoided about $1.7 billion over a full year. [18] A program with that finding has every reason to keep a gate, and a comptroller will say so before I finish the sentence. Behind it stands a second worry. Senators have asked large Medicare Advantage insurers for records on AI in coverage decisions, with a lawsuit over one such tool unresolved, because software can speed a no as easily as a yes. [19]
My read is that both risks are real and the wait answers neither. The delay the auditors documented sits in the fax queue before the clinical judgment and in the notice after it. A clock on the handling leaves the judgment alone. In the six-plan evaluation, decisions came more than three times faster and the approval rate moved from 59.9 percent to 60.3. [15] The new contract keeps every final decision with VA and holds the contractor's denial recommendations to a target under 5 percent. [7]
On the software risk, California bars a decision tool from denying, delaying, or modifying care, and Medicare's AI review model leaves every non-payment call to a clinician. [20][21] VA can go one line further: software may approve, and only a clinician may deny.
Four sentences for section 8.5
The cheapest second yes is the one Sager never has to ask for, and VA has started down that road. In August 2025 it lengthened new community care authorizations to a full year for 30 kinds of care, cardiology, outpatient mental health, oncology, and pain management among them, where some referrals had been reevaluated every 90 to 180 days. "No Veteran should have their health care disrupted by red tape," Secretary Doug Collins said. [22] Chiropractic care is not on the list. Neither is physical therapy as such, or home health. Medicare Advantage sets the wider standard: an approval for a course of treatment "must be valid for as long as medically necessary." [23]
Some asks can be settled before they are written. A VA cardiology clinic that sent about 60 percent of its consults to electronic consultation cut its median wait from 24 days to 13, and AI tools now do a version of that work at the first visit. [24] In a randomized trial of 2,069 patients in China, published in Nature Medicine, a tool that took the history and suggested tests ahead of the specialist shortened consultations by 28.7 percent, and an eight-state U.S. health system says 72 percent of clinicians using its tool reported better workups. [25][26] None of those studies counted repeat approvals, and reviews call the e-consult evidence modest, so I would treat them as tests for VA to run on its own numbers. [27]
Two more are worth borrowing. Exempting what is nearly always approved is harder than it sounds. Texas passed its gold card law in 2021, about 3 percent of physicians had earned one, by the state's count, and Texas rewrote the law in 2025. California's version exempts services with at least a 90 percent approval rate, starting in 2028. [28][29] And approval should stop being the last thing the record shows. Denver Health began tracking whether the specialist's note came back to the referring clinician, and the share rose from 18 percent to 73 percent in two years. [30]
For the paper that still arrives, VA owns the tools. Two of the four facilities the auditors visited had put AI on the fax queue to sort and label requests, and staff said it sped up sorting and caught duplicates. [2] VA's national e-fax tool cut handling time at its Bay Pines medical center from 4.5 minutes a document to 3.1, by VA's account, and its AI inventory lists three more efforts aimed at community care faxes and records. [31][32] Vendors sell the same thing commercially, and one claims a Florida health system's fax-to-transcription time fell from 48 hours to 10 minutes, which is a vendor's account of an unnamed customer. [33] The audit's first recommendation asks VHA to assess automation, "including artificial intelligence-based solutions." [2] That many tools pointed at the same paperwork is an argument for one intake service.
The rest is four sentences, and section 8.5 of the work statement is where they go. The clock starts when the contractor or VA first receives the request. A request for documents that were never on the list does not stop it. It stops when the veteran is told. VA publishes the result every quarter, by facility and by region, split into the contractor's days and VA's.
The Office of Veterans Community Care, which VHA announced in July as the successor to the Office of Integrated Veteran Care, owns the policy, and the contracting officer for the new contracts owns the work statement and the task orders. [2] The surveillance plan says "VA will review the QASP annually at a minimum," which is where the whole-trip number can become a performance objective the two sides share. [9] The first three sentences cost a decision. The fourth goes one step past the audit's sixth recommendation, which asks only for internal oversight. Two other recommendations finish the job: a real pending status, so that a request still under review stops being closed as a denial, and a notice to the veteran every time. [2]
If you run a community care office, you do not have to wait for any of it. Pull ten closed requests, find the fax cover sheets, and compare the dates. The auditors did it 124 times.
The day he hears
The request VA logged at 13 days took 35. On the other end of it were a doctor's office and a veteran doing what Linda Gill and John-Paul Sager do every few months, which is ask and then wait to hear. [2]
A fax machine wrote down the day the doctor asked. The contract should write down the day the veteran heard.
Gill has already said the rest, in seven words. "After what they've done for us? Please." [1]
Let's roll.
— Mary
Mission Meets Tech
The views expressed in this newsletter are my own and do not represent the official position of any organization. This content is for informational purposes only.
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Sources
[1] Tony Leys, "Congress Looks To Ease Restrictions on Veterans' Use of Non-VA Clinics and Hospitals," KFF Health News, August 6, 2025. Source for: John-Paul Sager, a Marine Corps and Army veteran of Denver, Iowa, whose visits to a private chiropractic clinic about 15 miles away in Waterloo VA pays for because the local VA does not offer the care, who must get fresh VA approval every few months, which often requires several phone calls, and who said "It seems like it takes entirely too long" and, of the VA, "You just feel like you're being taken care of by your own"; Linda Gill, office manager of Vanderloo Chiropractic Clinic, where about a dozen veterans use the program, on VA paying about $34 for a typical visit, a rate comparable to private insurance, with more burdensome paperwork, the clinic's leaders having considered leaving the program, and her plea, "After what they've done for us? Please"; and Marcus Lewis, a Navy veteran and chief executive of First Care Health Center in Park River, North Dakota, "I think a lot of folks just don't want to fight the system." The article does not say which form was used or how long any single approval took. https://kffhealthnews.org/rural-health/veterans-rural-care-private-facilities-legislation/
[2] Department of Veterans Affairs Office of Inspector General, "Audit of Processing of Community Care Requests for Services," 25-03946-211, September 24, 2026, signed by Larry M. Reinkemeyer, Assistant Inspector General for Audits and Evaluations. Source for: the comparison of Consult Toolbox receipt dates with fax cover sheets in veterans' medical records for a sample of 124 requests at four facilities, about 22 percent of which did not match; the examples of 7 days recorded against 21 "based on the date shown on the faxed request" and 13 days recorded against 35 actual; the Community Care Field Guidebook standard of a decision made, documented, and communicated within three business days of receipt; about 2.6 million requests at 132 facilities, October 1, 2024 through January 31, 2026; about 45 percent decided within three business days and an average of about eight, both calculated by the auditors from VA's data; about 54 percent with a recorded notification, about 46 percent without, and an average of about 12 days to notification; about 17 percent (about 445,000) with a recorded notification within three business days, counted from the earliest letter to either the provider or the veteran because the system could not tell the two apart before May 2025; VHA officials' statement that the Consult Toolbox "cannot automatically capture the actual date" of receipt; staff use of the provider's signature date, the fax transmission date, or the entry date; "no established national procedure for verifying the correctness of receipt dates"; staff at the four visited facilities reporting that most requests arrive by electronic fax; requests that "can remain in fax queues for up to two months"; two sites with more than 1,700 requests not yet documented; a third site where managers stopped entering new requests and redirected staff to authorizations, with more than 3,700 unentered as of September 2025; 30 community care nurses keeping individual spreadsheets; the instruction to "close requests on the fourth day after the request was entered into the Consult Toolbox," the missing "needs more time" option, the "denial" selection with the comment "still under provider review," the advice to veterans to follow up with primary care, and the community care chief's confirmation that the practice was still in effect as of April 2026; the guidebook statement that "no additional veteran care should be provided or paid for" until notification, and the warning of "potentially leaving the veteran or provider liable for the cost of the care"; mental health requests averaging 10 days with about 68 percent late; staff reports of delays "sometimes more than 60 days"; the referral of three cases involving delays in care to the Office of Healthcare Inspections; the nurse's statement that staff were told to "fax notifications only to providers and not to notify veterans"; the audit's interviews with VA officials and facility staff; two of the four visited facilities having recently implemented automation tools "that use artificial intelligence to sort and label requests received via electronic fax"; the memorandum of August 27, 2026 signed by John Figueroa as Acting Under Secretary for Health, "VHA concurs with the recommendations made to the Under Secretary for Health"; the six recommendations and their July 2027 target dates, including recommendation 6 on routine oversight of data accuracy and timeliness, which does not call for publication; VHA's statement that review and decisions remain at the facility level; and the July 13, 2026 announcement of the VHA Office of Veterans Community Care. The 1.2 million figure is the author's calculation (46 percent of about 2.6 million). https://www.vaoig.gov/sites/default/files/reports/2026-09/vaoig-25-03946-211.pdf
[3] Department of Veterans Affairs, Veterans Health Administration, "Request for Service and Durable Medical Equipment - Community Care," updated June 3, 2026, and VA Form 10-10172, Community Care Provider Request for Service. Source for: an RFS being required "when a Veteran needs care beyond what is already authorized in an active referral," including additional visits, a new specialty referral, or a procedure outside the original Standardized Episode of Care; and the statement that VA notifies the provider through the provider's preferred method, with no mention of notice to the veteran. https://department.va.gov/vha/community-care/care-coordination/request-for-service-requirements/ and https://www.va.gov/vaforms/medical/pdf/VA%20Form%2010-10172.pdf
[4] Department of Veterans Affairs Office of Inspector General, statement of Leigh Ann Searight, Deputy Assistant Inspector General for Audits and Evaluations, before the Senate Committee on Veterans' Affairs, "Building a 21st Century VA Health Care System: Assessing the Next Generation of VA's Community Care Network," February 11, 2026. Source for: the statement that delays and failures in processing requests for additional services "can hinder follow-up care for veterans." https://www.veterans.senate.gov/services/files/C6935C6C-BCC8-41E7-86B9-AC6ED2740DFB
[5] Help article for clinicians published by a national therapy network, on VA Requests for Services, updated August 12, 2026. Source for: the instruction to return the signed form "at least 30 days in advance of the expiration date" and the statement that VA "requires a minimum of 30 days to review, approve, and issue a renewed authorization." Company guidance to its own clinicians; the network is not named here. https://help.growtherapy.com/en/articles/15878153-when-a-veteran-needs-more-care-rfs-instructions
[6] HadIt.com, index of VA CCN Next Gen solicitation and award documents, checked October 11, 2026. Source for: four indefinite-delivery contracts signed August 31, 2026, with the period of performance listed January 1, 2027 through December 31, 2036, and no medical task orders posted to USAspending.gov as of the index's check. Third-party index; the awardees are not named here. https://hadit.com/ccn-next-gen-documents/
[7] Department of Veterans Affairs, CCN Next Generation Medical, Performance Work Statement, East, version 5, and West, version 5, April 9, 2026. Source for: section 1, health care delivery (HCD) starting station by station on contracting officer acceptance, "no sooner than 90 days from contract award"; section 8.2.5, contractor review of requests "beginning at the start of HCD"; section 7.1, the unique identifier for every RFS and "VA has the sole responsibility to make final decisions based on the Contractor's UM recommendation"; section 8.2, utilization review against VA medical policy; section 8.5, "Timeliness of UM Recommendations," with standard requests "reviewed and submitted to VA within one (1) business day of receipt of complete RFS package," urgent requests within four hours of a complete package, and incomplete requests returned to the provider with no timeframe stated; section 8.1.6, the target above 90 percent, the denial recommendation target under 5 percent, "Year one (1) - Establish Baseline," and required data fields including "Request Received Date/Time" and "Decision Date/Time," with no field for the date of notice; section 8.1.5, the quarterly utilization report "beginning 12 months after full HCD"; section 6.2, the portal's display of RFSs; and section 3.1, appointment timeliness measured "from the date the referral is approved by VA to the initial date of service captured on the first claim," 28 days for specialty care. No sentence in sections 7 or 8 sets a time for VA's decision or for notice to the veteran. Pre-award versions hosted by a third party; task orders may differ. https://hadit.com/wp-content/uploads/2026-04-09_VA-CCN-Next-Gen-Medical-PWS-East-v5.pdf and https://hadit.com/wp-content/uploads/2026-04-09_VA-CCN-Next-Gen-Medical-PWS-West-v5.pdf
[8] Department of Veterans Affairs, CCN Next Generation Medical, Contractor Manual, version 2, February 24, 2026. Source for: the manual's convention, at page 8, that "For PWS sections that do not have associated content in the Medical Manual, the corresponding section is marked as 'Reserved'"; section 8.5, "Timeliness of UM Recommendations," marked Reserved under that convention; and Table 13, the RFS scenario, including portal submission and EDI 278 through DAS. Pre-award version hosted by a third party. https://hadit.com/wp-content/uploads/2026-02-24_VA-CCN-Next-Gen-Medical-Contractor-Manual-v2.pdf
[9] Department of Veterans Affairs, CCN Next Generation Medical, Quality Assurance Surveillance Plan, East and West, version 2, February 24, 2026, and Incentive/Disincentive Plan, East, January 16, 2026. Source for: performance objectives PO1.1 through PO5.1 covering network, customer service, claims, medical documentation, and value-based care, with none on RFS or utilization management; "VA will review the QASP annually at a minimum"; and incentives and disincentives limited to PO2.7 (Tier 3 adverse credit reporting tickets in the VA ticketing tool) and PO5.1 (value-based network coverage). The performance requirements summary that holds the acceptable quality levels is not in the public document set. https://hadit.com/wp-content/uploads/2026-02-24_VA-CCN-Next-Gen-Medical-QASP-East-v2.pdf and https://hadit.com/wp-content/uploads/2026-02-24_VA-CCN-Next-Gen-Medical-QASP-West-v2.pdf and https://hadit.com/wp-content/uploads/2026-01-16_VA-CCN-Next-Gen-Medical-Incentive-Disincentive-Plan-East.pdf
[10] U.S. House of Representatives, Committee on Veterans' Affairs, hearing of January 22, 2026 on the next generation of the Community Care Network. Source for: VA's chief financial officer answering "Yes, ma'am" when a member asked whether the network would be fully operational "in 2028." Testimony; the exchange did not specify fiscal or calendar year. https://www.congress.gov/event/119th-congress/house-event/118882/text
[11] Centers for Medicare & Medicaid Services, "CMS Interoperability and Prior Authorization Final Rule CMS-0057-F," fact sheet, January 17, 2024. Source for: the Prior Authorization API that "can identify documentation requirements for prior authorization approval" and "supports a prior authorization request and response," required beginning January 1, 2027; the requirement that "impacted payers must provide a specific reason for denied prior authorization decisions," beginning in 2026; and the requirement to add prior authorization information to the Patient Access API by January 1, 2027. Impacted payers are Medicare Advantage organizations, Medicaid and CHIP programs and managed care plans, and qualified health plan issuers on the federal exchanges. The rule requires payers to offer the interface and does not require providers to use it. The rule does not apply to VA. https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-prior-authorization-final-rule-cms-0057-f
[12] Centers for Medicare & Medicaid Services, "Improving Prior Authorization Processes," frequently asked questions on the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). Source for: "The prior authorization decision timeframe clock starts when an impacted payer receives a prior authorization request"; the statement that the clock "does not stop or restart if the payer requests additional documentation that was not disclosed to the provider when they submitted the original request"; extensions where program rules permit them; seven calendar days for standard and 72 hours for expedited requests; and the public metrics, including approval and denial rates and "the average and median time that elapsed between the submission of request and a determination by the payer," due for calendar year 2025 by March 31, 2026. The rule does not apply to VA. https://www.cms.gov/initiatives/burden-reduction/overview/interoperability/frequently-asked-questions/improving-prior-authorization-processes
[13] Centers for Medicare & Medicaid Services, "Electronic Prior Authorization: Industry Commitments & Finalized and Proposed Rulemaking," and Department of Health and Human Services, proposed rule CMS-0062-P, docket CMS-2026-1255, released April 10, 2026, with comments closed June 15, 2026. Source for: the HL7 Da Vinci Coverage Requirements Discovery, Documentation Templates and Rules, and Prior Authorization Support implementation guides and the steps they support (requesting and receiving coverage requirements, populating documentation using templates and rules, and submitting the request and receiving the payer's response); and the proposal to "adopt FHIR for PA-related HIPAA Administrative Simplification transactions in place of the X12N 278 transaction standard." Proposed, not final. https://www.cms.gov/files/document/electronic-prior-authorization-industry-commitments-finalized-proposed-rulemaking.pdf and https://www.regulations.gov/document/CMS-2026-1255-0001
[14] Healthcare Dive, "Insurers committed to cutting prior authorizations have eliminated 11% so far," April 7, 2026, and AJMC, frequently asked questions on prior authorization reform, August 26, 2026. Source for: commitments by health plans covering 270 million Americans, AJMC's figure (Healthcare Dive says more than 250 million); the 2027 target of answering at least 80 percent of electronic prior authorization requests in real time, for requests submitted with all needed clinical documentation; and the American Medical Association survey finding that "only 1 in 3 (33%) believe the latest insurer pledge will make a meaningful difference." The commitments are voluntary. https://www.healthcaredive.com/news/insurer-prior-authorization-commitment-update-ahip-bcbsa/816819/ and https://www.ajmc.com/view/faq-prior-authorization-reform-will-changes-go-far-enough-by-2027-
[15] RTI International, "Evaluation of the Fast Prior Authorization Technology Highway Demonstration," final report for America's Health Insurance Plans, February 2021. Source for: six participating health plans and more than 40,000 prior authorization transactions covering prescriptions and procedures; "The median time from prior authorization request to decision fell from 18.7 hours to 5.7 hours"; 58 percent of experienced users reporting fewer faxes; and approval rates of 59.9 percent before and 60.3 percent after. Industry-sponsored and independently evaluated; the tools tested predate the FHIR standards. https://www.ahip.org/documents/Fast-PATH-Evaluation.pdf and https://healthcare.rti.org/article/evaluation-fast-prior-authorization-technology-highway-demonstration
[16] Defense Health Agency, TRICARE Operations Manual, Chapter 1, Section 3, and U.S. Government Accountability Office, "Defense Health Care: Opportunities to Improve Future TRICARE Managed Care Support Contract Transitions," GAO-20-39, November 2019. Source for: authorizations issued "within two business days following receipt of the request and all required information," 90 percent within two business days and 100 percent within five; and the companion referral standard of 90 percent within two business days of receipt and 100 percent within three, which GAO confirms at page 16, footnote 20. The TRICARE contractor makes the determination. Requirements; no public data on contractor performance against them was found. https://manuals.health.mil/pages/DisplayManualHtmlFile/2025-04-28/ChangeOnly/to15/c1s3.html and https://www.gao.gov/assets/gao-20-39.pdf
[17] 45 CFR 160.103; VHA Directive 1605.02; and Department of Veterans Affairs, CCN Next Generation Medical, solicitation 36C10G26R0003, conformed copy, April 23, 2026, section B.11. Source for: "the veterans health care program under 38 U.S.C. chapter 17" listed as a health plan; VHA as a HIPAA covered entity; and the solicitation's instruction to "consider FHIR as it becomes standardized." That a final rule would reach VA's requests is the author's inference. https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-160/subpart-A/section-160.103 and https://www.va.gov/VHAPUbLICAtIons/ViewPublication.asp?pub_ID=8302 and https://hadit.com/wp-content/uploads/2026-04-23_VA-CCN-Next-Gen-Medical-Solicitation-36C10G26R0003-Conformed.pdf
[18] Department of Veterans Affairs Office of Inspector General, "Audit of Veterans' Community Care Eligibility Determinations," 25-01014-139, June 17, 2026. Source for: "About 25 percent of 1.4 million veterans sent to community care did not meet eligibility requirements" in the first quarter of fiscal 2025, and the estimate that VHA could have avoided about $440 million in that quarter, or about $1.7 billion over a full fiscal year. https://www.vaoig.gov/reports/audit/audit-veterans-community-care-eligibility-determinations
[19] Becker's Payer Issues, report of July 15, 2026 on letters from two senators to three Medicare Advantage insurers requesting records on the use of AI and algorithms in coverage decisions, and on a pending lawsuit over one such tool. Reported allegations; the case is unresolved, and the insurers are not named here. https://www.beckerspayer.com/payer/medicare-advantage/senators-press-unitedhealth-humana-cvs-on-ai-driven-medicare-advantage-coverage-decisions/
[20] California Department of Insurance, "Use of Artificial Intelligence, Algorithms and Other Software Tools in Utilization Management," Guidance SB 1120:1, May 5, 2025. Source for: "The decision support tool shall not deny, delay, or modify health care services based on medical necessity" and "A determination of medical necessity shall be made only by a licensed physician or licensed health care professional." State law. https://www.insurance.ca.gov/0250-insurers/0500-legal-info/0200-regulations/HealthGuidance/upload/SB-1120-1-Guidance-Use-of-Artificial-Intelligence-Algorithms-and-Other-Software-Tools-in-Utilization-Management.pdf
[21] Centers for Medicare & Medicaid Services, "WISeR (Wasteful and Inappropriate Service Reduction) Model." Source for: "All recommendations for non-payment are determined by appropriately licensed clinicians." Six states, 2026 through 2031; participants receive a percentage of averted expenditures. https://www.cms.gov/priorities/innovation/innovation-models/wiser
[22] Department of Veterans Affairs, "VA offers yearlong community care authorizations for 30 services," news release, August 2025, as posted by the Wilmington VA Medical Center on August 5, 2025. Source for: "extending the length of new VA community care authorizations to one year for 30 standardized types of care"; "some VA community care specialty referrals were reevaluated every 90 to 180 days"; Secretary Doug Collins, "No Veteran should have their health care disrupted by red tape"; and the list of 30 services, which includes cardiology, mental health outpatient, oncology and hematology, and pain management and does not include chiropractic care, physical therapy, or home health; the list does include Physical Medicine & Rehabilitation (Physiatry). https://www.va.gov/wilmington-health-care/news-releases/va-offers-yearlong-community-care-authorizations-for-30-services/
[23] 42 CFR 422.112(b)(8). Source for: "Approval of a prior authorization request for a course of treatment must be valid for as long as medically necessary" and "a minimum 90-day transition period for any active course(s) of treatment." Medicare Advantage only. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-C/section-422.112
[24] American Journal of Managed Care, 2019 (PubMed 31120719). Source for: a VHA outpatient cardiology clinic that triaged about 60 percent of consults to e-consult within an active referral management process and cut its median wait from 24 days to 13. Direct care, not community care. https://pubmed.ncbi.nlm.nih.gov/31120719/
[25] "An LLM chatbot to facilitate primary-to-specialist care transitions: a randomized controlled trial," Nature Medicine, doi:10.1038/s41591-025-04176-7. Source for: 2,069 analyzed participants at two hospitals in China; a pre-visit tool that took the medical history and suggested preliminary diagnoses and tests; and a "28.7% reduction" in physician consultation duration against the comparison group. The trial did not measure referrals or authorizations. https://link.springer.com/article/10.1038/s41591-025-04176-7
[26] Eve Cunningham et al., NEJM Catalyst, 2024, as listed by Providence Digital Commons. Source for: a clinical decision tool with more than 4,000 active monthly clinician users across an eight-state health system, 72 percent of whom said it improved their clinical management and workups. Self-reported; the lead author founded the tool, which is not named in the text. https://digitalcommons.providence.org/publications/9048/
[27] Systematic review of electronic consultation outcomes, PubMed Central PMC7647247. Source for: the characterization of the evidence for e-consults as modest. https://pmc.ncbi.nlm.nih.gov/articles/PMC7647247/
[28] American Medical Association, "Understanding the Texas Gold Card Law: Advocacy and legislative efforts in prior authorization," October 11, 2024; Texas Medical Association, Texas Medicine, December 2023; and MDedge, Federal Practitioner, "State-Mandated Gold Card Programs Ease Prior Authorization Burdens, Offer Little Relief, Experts Say." Source for: the 2021 Texas law exempting physicians with a 90 percent approval rate for a service over a six-month period; the Texas Department of Insurance count, from 2023, that about 3 percent of physicians had earned gold card status; and the 2025 revision, HB 3812, with a one-year review period from September 1, 2025. https://www.ama-assn.org/practice-management/prior-authorization/understanding-texas-gold-card-law-advocacy-and-legislative and https://www.texmed.org/ShieldGoldCard/ and https://www.mdedge.com/fedprac/avaho/article/272646/mixed-topics/state-mandated-gold-card-programs-ease-prior-authorization-burdens-offer-little-relief-experts-say
[29] Mercer, "Prior authorization comes under greater scrutiny," April 29, 2026. Source for: California SB 306 exempting services with "at least a 90% approval rate" from prior authorization starting January 1, 2028, in state-regulated plans. Secondary source. https://www.mercer.com/en-us/insights/us-health-news/prior-authorization-comes-under-greater-scrutiny/
[30] American College of Physicians, "Closing-the-Loop (Care Coordination)," hosted by the CMS Innovation Center. Source for: Denver Health's average close-the-loop rate, the share of specialty referrals with a consultation note returned to the referring clinician, rising from 18.2 percent in January 2017 to 73.3 percent in January 2019 across 43 specialty clinics. Measures notes returned, not visits completed. https://www.cms.gov/priorities/innovation/files/x/tcpi-san-pp-loop.pdf
[31] VA News, article on the AI-Driven eFax Fix; the page shows no publication date. Source for: average handling time per document falling from 4.5 minutes to 3.1 at the C.W. Bill Young VA Medical Center in Bay Pines, Florida, and continued national rollout. VA-reported; the article does not mention Requests for Services. https://news.va.gov/146452/ai-tool-va-process-community-care-faster
[32] Department of Veterans Affairs, AI Use Case Inventory 2025, January 2026 web version. Source for: use cases VA-25-2865 (fax automation aimed at faxed RFS), VA-25-1430, "Deduplication in Record Management" (flags urgent RFS records and missing signatures; pre-deployment), and VA-25-2831 (community care fax relabeling, a pilot). https://department.va.gov/ai/wp-content/uploads/sites/26/2026/01/VA-AI-Use-Case-Inventory-2025-Web.xlsx
[33] Vendor customer story on AI transcription of faxed referrals, undated, 2026 copyright. Source for: average turnaround "reduced from 48 hours to 10 minutes" at "a large, community-focused health system in Florida." Vendor marketing, cited as an example of the category; the vendor is not named here. https://www.notablehealth.com/customer-stories/optimizing-referral-management-with-ai
Sources verified as of November 12, 2026.
