CMS’s Interoperability and Prior Authorization final rule, which was announced Jan. 17, includes new requirements that CMS said will improve prior authorization.[1] They apply to Medicare Advantage plans, state Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities and qualified health plan (QHP) issuers on the federally facilitated exchanges (FFEs). For one thing, CMS is requiring the payers (except for QHP issuers on the FFEs) to send prior authorization decisions in 72 hours for expedited requests and seven days for standard requests. The payers also must provide a specific reason for denying prior authorization and publicly report some prior authorization metrics on their website every year. The compliance deadline is Jan. 1, 2026. None of the new prior authorization requirements apply to drugs.
TABLE E1: Prior Authorization Decision Timeframes For Impacted Payers Beginning In 2026 (Excluding Drugs)
|
Payer |
Final Expedited Prior Authorization Decision Timeframes |
Final Standard Prior Authorization Decision Timeframes |
|---|---|---|
|
MA Organizations and Applicable Integrated Plans |
As expeditiously as the enrollee’s health condition requires, but no later than 72 hours after receiving the request.* 42 CFR 422.572(a) 42 CFR 422.631(d)(2)(iv) |
As expeditiously as the enrollee’s health condition requires but no later than 7 calendar days after receiving the request for the standard organization determination* and standard integrated organization decision. 42 CFR 422.568(b)(1) 42 CFR 422.631(d)(2)(i)(B) |
|
Medicaid Managed Care Plans |
As expeditiously as the enrollee’s health condition requires and no later than 72 hours after receipt of the request for service. 42 CFR 438.210(d)(2) |
As expeditiously as the enrollee’s condition requires and within State established timeframes that may not exceed 7 calendar days after receiving the request for service. 42 CFR 438.210(d)(1) |
|
CHIP Managed Care Entities |
As expeditiously as the enrollee’s health condition requires but no later than 72 hours after receipt of the request for service, unless a shorter minimum time frame is established under state law. 42 CFR 457.1230(d) |
As expeditiously as the enrollee’s condition requires but no later than 7 calendar days after receiving the request for service, unless a shorter minimum time frame is established under state law. 42 CFR 457.1230(d) |
|
Medicaid FFS |
As expeditiously as a beneficiary’s health condition requires, but in no case later than 72 hours after receiving the request, unless a shorter minimum time frame is established under state law. 42 CFR 440.230(e)(1)(ii) |
As expeditiously as a beneficiary’s health condition requires, but in no case later than 7 calendar days after receiving the request, unless a shorter minimum timeframe is established under state law. 42 CFR 440.230(e)(1)(i) |
|
CHIP FFS |
In accordance with the medical needs of the patient, but no later than 72 hours after receiving the request for an expedited determination. 42 CFR 457.495(d)(1) |
In accordance with the medical needs of the patient, but no later than 7 calendar days after receiving the request for a standard determination. 42 CFR 457.495(d)(1) |
|
QHP Issuers on the FFEs |
As soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claim. 45 CFR 147.136(b)(3)(i) |
A reasonable period of time appropriate to the medical circumstances but not later than 15 days after receipt of the claim. 45 CFR 147.136(b)(3)(i) |
*Applicable integrated plans may have shorter timeframes as required by a state ( 42 CFR 422.629(c) allows states to implement shorter timeframes).
