The CMS Prior Authorization Rule: What Practices Should Know
The CMS Interoperability and Prior Authorization final rule (CMS-0057-F) requires certain payers to send prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests. Payers must also give a specific reason when a request is denied. Most operational provisions begin January 1, 2026, and API requirements apply from January 1, 2027.
Which payers are covered
According to CMS, the rule applies to Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and qualified health plan issuers on the federally facilitated exchanges. CMS notes that qualified health plan issuers on the federally facilitated exchanges are excluded from the decision timeframe requirement. Commercial group plans outside these programs are not covered by this rule.
Decision timeframes
- Expedited requests: 72 hours
- Standard requests: seven calendar days
Denials must include a specific reason
Starting in 2026, covered payers must provide a specific reason for any denied prior authorization, regardless of the method used to send the decision.
Public reporting and API dates
Covered payers must post prior authorization metrics on their websites each year, with the first set due by March 31, 2026. API requirements must be met by January 1, 2027. CMS states that drug prior authorizations are excluded from the API and prior authorization provisions.
What this means for practice workflows
The rule sets expectations for payers, not for practices. Practices still need clear workflows: track the date of each request, record decisions, and route denial reasons to clinicians. See how prior authorization works and common delays and how to reduce them.
A note on accuracy
Details of the rule can change and payer implementation varies. Check the CMS source below and your payer contracts before changing policy. This article is general information, not legal advice.
Related services from our team: Prior authorization support service | Complimentary workflow assessment.
Sources
Request Your Complimentary Workflow Assessment
A complimentary, no-PHI conversation about your practice's administrative workload.
Request Your Complimentary Workflow AssessmentFrequently Asked Questions
How fast must payers respond to prior authorization requests under CMS-0057-F?
72 hours for expedited requests and seven calendar days for standard requests, for the payers covered by the timeframe requirement.
Does the rule apply to prescription drugs?
CMS states that drug prior authorizations are excluded from the API and prior authorization provisions.
Does the rule apply to every commercial plan?
No. It applies to the payer types CMS lists in its final rule fact sheet.