CMS tightens prior-auth workflows

The Centers for Medicare & Medicaid Services wants health plans to answer many drug prior-authorization requests on a clock — 24 hours for urgent cases and 72 hours for standard ones. (cms.gov) CMS released the proposed rule on April 10, and it was published in the Federal Register on April 14 with comments due by June 15, 2026. The proposal applies to Medicare Advantage plans, Medicaid managed care plans, state Medicaid and Children’s Health Insurance Program agencies, CHIP managed care entities, and qualified health plan issuers on the federally facilitated exchanges. (cms.gov) (federalregister.gov) Prior authorization is the insurer’s pre-approval step before a patient can get some drugs paid for. CMS is proposing to move that process into standardized electronic transactions so prescribers, pharmacies and plans can exchange requests, decisions and status updates through application programming interfaces instead of phone calls and faxed forms. (cms.gov) The new proposal fills a gap left by CMS’s 2024 interoperability and prior-authorization rule, which set electronic prior-authorization requirements for medical items and services but did not cover drugs. That 2024 rule also required impacted payers to build Health Level 7 Fast Healthcare Interoperability Resources interfaces, a common format for moving health data between systems. (cms.gov 1) (cms.gov 2) CMS said the 2026 proposal would also require plans to send specific denial reasons, publicly report prior-authorization metrics, and disclose claims denials and appeals outcomes. The agency said those changes are meant to show how often requests are rejected, how often patients appeal, and how often plans reverse themselves. (cms.gov 1) (cms.gov 2) Hospitals have backed the push for electronic drug prior authorization. The American Hospital Association said the proposal would establish electronic standards for drug prior authorizations and extend the 2024 framework to medications that were left out of the earlier rule. (aha.org) Lawyers advising insurers and providers said the proposal turns prior authorization into a system that must be visible in operations, not just documented in policy manuals. Sheppard Mullin wrote that buyers and regulated plans would need workflows that are routable, trackable and auditable across programs. (natlawreview.com) The rule is still a proposal, and CMS can revise it after the June 15 comment deadline. For plans, pharmacy benefit managers, hospitals and software vendors, the next two months are the window to argue over the deadlines, the data standards and how much of the process must be exposed in public reporting. (federalregister.gov) (cms.gov)