Effective 2026

In response to mounting criticism of prior authorization delays by payers, the Centers for Medicare & Medicaid Services (CMS) has established new rules to expedite the process. Effective from 2026, health plans are mandated to provide prior authorization decisions within three days for urgent requests and seven days for standard requests. The regulations apply to various programs, including Medicare Advantage, Medicaid, Children's Health Insurance Program, Medicaid managed care, and qualified health plans. Payers must offer reasons for denial, along with guidance on resubmission or appeal. The CMS is also requiring the implementation of application programming interfaces (APIs) to enhance electronic automation, with a phased approach starting in 2027. The changes aim to reduce administrative burdens, enhance health outcomes, and generate an estimated $15 billion in savings over a decade. Critics argue that current prior authorization practices strain the healthcare system and serve as a tool for delaying coverage of expensive procedures. The move has received support from industry groups like the Medical Group Management Association and the Workgroup for Electronic Data Interchange, while some organizations, like Premier, Inc., believe that the rule falls short of providing timely care and incentivizing real-time processes. CMS will enforce the rules through the Health Insurance Portability and Accountability Act, aiming to protect patients from arbitrary critical care denials and delays caused by prior authorization abuse.

In response to mounting criticism of prior authorization delays by payers, the Centers for Medicare & Medicaid Services (CMS) has established new rules to expedite the process. Effective from 2026, health plans are mandated to provide prior authorization decisions within three days for urgent requests and seven days for standard requests. The regulations apply to various programs, including Medicare Advantage, Medicaid, Children's Health Insurance Program, Medicaid managed care, and qualified health plans. Payers must offer reasons for denial, along with guidance on resubmission or appeal. The CMS is also requiring the implementation of application programming interfaces (APIs) to enhance electronic automation, with a phased approach starting in 2027. The changes aim to reduce administrative burdens, enhance health outcomes, and generate an estimated $15 billion in savings over a decade. Critics argue that current prior authorization practices strain the healthcare system and serve as a tool for delaying coverage of expensive procedures. The move has received support from industry groups like the Medical Group Management Association and the Workgroup for Electronic Data Interchange, while some organizations, like Premier, Inc., believe that the rule falls short of providing timely care and incentivizing real-time processes. CMS will enforce the rules through the Health Insurance Portability and Accountability Act, aiming to protect patients from arbitrary critical care denials and delays caused by prior authorization abuse.