Definition · Pharmacy, Medicare enrollment, and access

Prior authorization (PA)

Prior authorization (PA) means a provider must get a health plan's approval before a service, procedure, or drug is covered. Under CMS rule CMS-0057-F, Medicare Advantage, Medicaid, and CHIP payers face deadlines starting in 2026. They must decide expedited requests within 72 hours and standard requests within 7 calendar days.

What prior authorization is

Prior authorization is a utilization management tool. Before a covered service is delivered, the provider submits clinical information showing it meets the plan's coverage rules. The plan approves, denies, or asks for more information. Without approval, the claim may be denied. It is common for imaging, specialty drugs, procedures, and durable medical equipment.

CMS finalized the Interoperability and Prior Authorization rule, CMS-0057-F, in January 2024. It applies to Medicare Advantage organizations, state Medicaid and CHIP programs and managed care plans, and qualified health plans on the federal exchanges. Starting January 1, 2026, all of these except the exchange plans must decide expedited requests within 72 hours and standard requests within 7 calendar days.

Also starting in 2026, impacted payers must give a specific reason for any denial and publicly report prior authorization metrics each year. Starting January 1, 2027, they must run a Prior Authorization API, plus Provider Access and Payer-to-Payer APIs. The rule does not cover traditional Medicare fee-for-service or employer plans outside the exchanges.

Questions

Prior authorization, answered

How long does prior authorization take under the new CMS rule?

Starting January 1, 2026, Medicare Advantage, Medicaid, and CHIP payers covered by CMS-0057-F must decide expedited requests within 72 hours and standard requests within 7 calendar days. Qualified health plans on the federal exchanges are excluded from these timeframes. Other plans follow their own contracts and state law.

What is the Prior Authorization API?

It is a standards-based interface that impacted payers must offer starting January 1, 2027. It lets a provider's system check whether prior authorization is needed, see documentation requirements, and submit requests electronically. It is built on HL7 FHIR standards to cut fax and portal work.

Does CMS-0057-F apply to traditional Medicare?

No. It applies to Medicare Advantage organizations and to state Medicaid and CHIP fee-for-service programs. It also covers Medicaid and CHIP managed care plans and qualified health plans on the federal exchanges. Traditional Medicare fee-for-service and most employer plans are outside its scope.

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Prior authorization (PA)

What prior authorization is

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