Faster prior authorization is coming: What it means for providers
Beginning Jan. 1, 2026, Centers for Medicare & Medicaid Services (CMS) will implement a final rule requiring standard prior authorization (PA) decisions to be made quicker. This change is designed to simplify and speed up the prior authorization process for federally regulated health insurers, including Medicare Advantage and Medicaid plans. Under this rule:
- Standard prior authorization requests must receive a decision within seven calendar days, reducing current timeframes (e.g., from 14 days in Medicare Advantage to seven days). Urgent or expedited requests have a turnaround time of 72 hours.
- Payers must provide specific reasons for denials to aid providers in resubmitting or appealing requests.
- The rule mandates the electronic exchange of patient data to support prior authorization and improve information exchange.
- Starting in 2026, payers will be required to publish key metrics such as approval and denial rates and average turnaround times.
What does this mean for providers?
- Faster decisions: Providers receive prior authorization decisions quicker, allowing them to proceed quicker with patient care and treatment plans.
- Improved patient experience: By minimizing delays and simplifying administrative tasks, providers are better positioned to deliver timely care, leading to greater patient satisfaction and improved health outcomes.
- Reduced administrative burden: With a stricter timeframe and the implementation of electronic prior authorization via application programming interfaces (APIs), providers spend less time navigating complex or prolonged authorization processes, which decreases paperwork and follow-ups.
- Clearer denial reasons: Payers are required to provide clear, standardized explanations for any prior authorization denials. This level of transparency helps providers quickly understand the reason for denial, enabling faster resubmissions or appeals and ultimately supporting better patient outcomes by reducing uncertainty.
The takeaway
The CMS final rule is intended to improve administrative efficiency, minimize delays in patient care and promote the use of technology to improve data sharing between providers and payers. The overarching goal is to streamline the prior authorization process by increasing speed, improving transparency and reducing the administrative burden on providers and patients.
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