The Centers for Medicare & Medicaid Services (CMS) released a final rule last week intended to expedite the prior authorization process for those covered by Medicare Advantage, Medicaid and Children’s Health Insurance Program (CHIP) plans.
Under the new rule taking effect in 2026, Medicare Advantage, Medicaid and CHIP plans will have 72 hours to answer urgent requests and seven days for a standard request. Affected payers will also be required to provide a specific reason when denying requests, as well as publicly report certain prior authorization metrics.
Additionally, the rule will require affected payers to implement a Health Level 7 Fast Healthcare Interoperability Resources standard application programming interface (API) to support electronic prior authorization. Payers must expand patient access to APIs beginning in 2027 to include information about prior authorizations. They must also implement a provider access API that providers can use to retrieve their patients’ claims, encounters and clinical and prior authorization data.
These actions addressing prior authorization come amid conversations on this same issue on Capitol Hill. The House Ways and Means Committee advanced the bipartisan Improving Senior’s Timely Acccess to Care Act in 2023, which gained traction following a report from the U.S. Department of Health and Human Services highlighting abuse of the prior authorization program and a letter signed by 233 House and 61 Senate members urging action by the CMS. The bill would have required plans to adopt a “real time” process for answering routinely approved items and a 24-hour response for any urgent requests. The release of the final rule may pre-empt further legislative action.
Members with questions should contact Megan Blue at the MHA.