CMS finalizes prior authorization rule

Posted on: 1/19/24

Earlier this week, the Centers for Medicare & Medicaid Services released a final rule requiring Medicare Advantage, Medicaid and federally facilitated Marketplace plans to streamline their prior authorization processes. The rule 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.