Knowledge Center

To combat growing criticism of prior authorization delays by payers, Centers for Medicare & Medicaid Services finalized a rule Wednesday that requires health plans to send prior authorization decisions within three days for urgent requests and seven days for standard requests starting in 2026.

The guidelines will affect Medicare Advantage, Medicaid, the Children's Health Insurance Program, Medicaid managed care and qualified health plans. It also requires payers to give patients and providers a reason for denying a prior authorization request, as well as instructing the other party how to resubmit the request or appeal the decision.

Organizations like the Medical Group Management Association, the Workgroup for Electronic Data Interchange (WEDI) and America's Physician Groups all applauded the rule change, with the latter calling prior authorizations a "blunt and misused instrument that poses obstacles to patients."

"Through the deployment of API technology, this historic final rule is expected to usher in a substantial reduction of administrative burden and unprecedented levels of health information exchange between health plans, providers, and the patients they serve," said WEDI President and CEO Charles Stellar.