CMS speeds prior authorization

The Centers for Medicare & Medicaid Services wants insurers in Medicare, Medicaid, and Affordable Care Act exchange plans to decide many drug prior authorizations in 24 to 72 hours instead of days or weeks. (cms.gov) CMS released the proposed rule on April 10, 2026, and it was published in the Federal Register on April 14 with a public comment deadline of June 15, 2026. (cms.gov) (federalregister.gov) The proposal would set decision deadlines of no later than 24 hours for urgent drug requests and 72 hours for standard requests, and it would require health plans to support electronic prior authorization for drugs. (cms.gov) Prior authorization is the insurer approval step that can block a prescription, scan, or treatment until a plan signs off on payment. CMS said its 2024 rule covered non-drug items and services, and this new proposal extends similar digital and timing rules to medications. (cms.gov 1) (cms.gov 2) The rule reaches Medicare Advantage plans, state Medicaid fee-for-service programs, Medicaid managed care plans, Children’s Health Insurance Program agencies and managed care entities, and Qualified Health Plan issuers on the federally facilitated exchanges. CMS also proposes adding small-group exchange plans sold through the federally facilitated Small Business Health Options Program. (cms.gov 1) (cms.gov 2) CMS is also using the rule to push broader data-sharing standards. The agency said it wants affected payers to update health information technology standards, report their application programming interface endpoints and usage metrics to CMS, and publicly report drug prior-authorization approval rates, denial rates, appeal outcomes, and decision times. (cms.gov 1) (cms.gov 2) Under the Health Insurance Portability and Accountability Act administrative simplification rules, the Department of Health and Human Services is also proposing national standards based on HL7 Fast Healthcare Interoperability Resources, or FHIR, for prior-authorization transactions. Those standards would apply to all HIPAA-covered providers, health plans, and clearinghouses that exchange prior-authorization requests and decisions electronically. (cms.gov) (cms.gov) The proposal builds on CMS’s January 17, 2024 final rule, which required prior-authorization application programming interfaces for non-drug items and services and gave affected payers until mostly January 1, 2027 to meet those API requirements. (cms.gov) Hospitals and physicians have spent years pressing for tighter rules. The American Hospital Association said in 2024 that CMS’s earlier rule would require more transparency and timeliness from payers, while the American Medical Association’s 2024 survey said 94% of physicians reported prior authorization delays for necessary care and 19% said it had led to a patient being hospitalized. (aha.org) (ama-assn.org) Insurers have defended prior authorization as a medical-management tool while also promising to trim it. AHIP said participating health plans announced voluntary commitments in 2024 to standardize electronic prior authorization, and AHIP said on April 7, 2026 that leading plans had eliminated 11% of prior authorizations across a range of medical services, equal to 6.5 million fewer authorizations. (ahip.org) (ahip.org) What happens next is procedural, not immediate: CMS will collect comments through June 15, 2026, then decide whether to finalize the deadlines, electronic workflows, and reporting rules that would move more of prior authorization off fax machines and into standardized digital systems. (federalregister.gov) (cms.gov)