Final rule reduces patient and provider burden by streamlining the prior authorization process

The Centers for Medicare & Medicaid Services (CMS) recently finalized the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), which sets requirements to improve the electronic exchange of health information and prior authorization processes for medical items and services. Together, these policies will improve prior authorization processes and reduce burdens on patients, providers, and payers, resulting in approximately $15 billion of estimated savings over ten years.

While prior authorization can help ensure medical care is necessary and appropriate, it can sometimes be an obstacle to necessary patient care when providers must navigate complex and widely varying payer requirements or face long waits for prior authorization decisions. This final rule establishes requirements for certain payers to streamline the prior authorization.

Beginning primarily in 2026, impacted payers, including Medicare Advantage (MA) organizations will be required to send prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests for medical items and services. For some payers, this new timeframe for standard requests cuts current decision timeframes in half. The rule also requires all impacted payers to include a specific reason for denying a prior authorization request, which will help facilitate resubmission of the request or an appeal when needed. Finally, impacted payers will be required to publicly report prior authorization metrics.

The rule also requires impacted payers to implement an electronic prior authorization application interface, 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. These new requirements for the prior authorization process will reduce administrative burdens on the healthcare workforce, empower clinicians to spend more time providing direct care to their patients, and prevent avoidable delays in care for patients.

The final rule is available to review here: https://www.cms.gov/files/document/cms-0057-f.pdf - PDF.

The fact sheet for the final rule is available here: https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f.