CMS finalizes prior auth rule

CMS has finalized a rule to streamline the prior authorization process and improve the electronic exchange of health information that it estimates will save $15 billion over 10 years.

The requirements generally apply to Medicare Advantage organizations, state Medicaid and Children’s Health Insurance Program agencies, Medicaid managed care plans, CHIP-managed care entities and qualified health plan insurers on the federally facilitated exchanges, according to a Jan. 17 CMS news release. The agency proposed the rule in December 2022.

Beginning primarily in 2026, certain payers will be required to include a specific reason when denying requests, publicly report certain prior authorization metrics, and send decisions within 72 hours for urgent requests and seven calendar days for standard requests.

Additionally, the rule requires impacted payers to implement a Health Level 7 (HL7®) Fast Healthcare Interoperability Resources (FHIR®) Prior Authorization application programming interface (API), which can be used to facilitate a more efficient electronic prior authorization process between providers and payers by automating the end-to-end prior authorization process. Medicare FFS has already implemented an electronic prior authorization API, demonstrating the efficiencies other payers could realize by implementing such an API. Together, these new requirements for the prior authorization process will reduce administrative burden on the healthcare workforce, empower clinicians to spend more time providing direct care to their patients, and prevent avoidable delays in care for patients.

A new Electronic Prior Authorization measure was also added for eligible clinicians under the Merit-based Incentive Payment System (MIPS) Promoting Interoperability performance category and eligible hospitals and critical access hospitals (CAHs) in the Medicare Promoting Interoperability Program to report their use of payers’ Prior Authorization APIs to submit an electronic prior authorization request.

Read the full Press Release:,1,dKynrJ-1XGta3svtiaTQSRADC76GWd1ZTD7IlZU3_qQMH_FKCXKmw_xtdmPNh8KxqqZPS0_O8ID4vwW3GF25HJdsHmiotczkGT1skZftkp9mnLOJyX47oQ,,&typo=1

Fact Sheet:,1,FNP7isPlaT5d6NiJNbsBPPr-28R8bYisjk9ISVxq7r-10PzabXD0NJ4SDzg0-WZRQPa15QWiMQyRmdmikEUMET_KFBXN356o5EDFEyVXYVTP1Xtr62ybFEeQoQ,,&typo=1

Final Rule:,1,0N-UFShA1oAGecPNqoYoXsgJLWLOQZbTGsHJrHC9maHGqvhTHgsajVSzPJ6xZ1NIIjrEqr5cUeoLqh5kStUdhuY–u_kCkzq8I4LLP7Gpe8N&typo=1