The Centers for Medicare & Medicaid Services has finalized its Interoperability and Prior Authorization Rule, which applies, inter alia, to Medicare Advantage plans.
Beginning in 2026, Medicare Advantage and other plans subject to the Final Rule will be required to respond to prior authorization requests within 72 hours for expedited (urgent) requests and seven calendar days for standard (non-urgent) requests. In addition, these plans will be required to provide providers with a specific reason for denying prior authorizations requests and to communicate the decisions via portal, fax, email, mail, or phone. Plans will also be required to publicly report prior authorization metrics.
In a press release announcing the Final Rule, HHS Secretary Xavier Becerra stated: “When a doctor says a patient needs a procedure, it is essential that it happens in a timely manner. Too many Americans are left in limbo, waiting for approval from their insurance company.” In a Fact Sheet accompanying the Final Rule, CMS stated that for “some payers, this new timeframe for standard request cuts the current decision timeframes in half.” With respect to the requirement that specific reasons for prior authorization denials must be provided, the Fact Sheet stated that the requirement will “help facilitate resubmission of the request or an appeal when needed.”
CMS’s press release announcing the Final Rule is linked here, its Fact Sheet is linked here, and the Final Rule is linked here.