CMS prior-authorization push
- CMS proposed faster electronic prior authorization, updated HIPAA transaction standards, and stronger interoperability across federal programs. - The rule would extend electronic prior authorization to drugs and require quicker insurer decisions. - If finalised, the change aims to reduce administrative delays that often cause missed refills and stalled referrals. (natlawreview.com) (medicalbuyer.co.in)
The Centers for Medicare & Medicaid Services has proposed new federal rules to make drug prior authorization faster, electronic, and easier to track. (cms.gov) CMS released the proposal on April 10, 2026, and it was published in the Federal Register on April 14 as rule CMS-0062-P. It applies to Medicare Advantage plans, state Medicaid fee-for-service programs, Medicaid and Children’s Health Insurance Program managed care plans, and qualified health plans sold on the federally facilitated exchanges. (federalregister.gov) (cms.gov) Prior authorization is the insurer’s advance signoff before a patient can get some drugs, scans, or procedures covered. CMS said the new proposal would require impacted payers to support electronic prior authorization for drugs and shorten decision deadlines across its programs. (cms.gov 1) (cms.gov 2) For Medicare Advantage drug requests, CMS proposed a 24-hour deadline for expedited decisions and a 72-hour deadline for standard decisions. The agency said those timeframes would align Medicare Advantage with existing Medicaid and exchange-plan standards. (cms.gov) (mcknights.com) The rule also reaches beyond deadlines. CMS proposed updated Health Insurance Portability and Accountability Act transaction standards built on Fast Healthcare Interoperability Resources, or FHIR, a format meant to let different health software systems exchange data in a common structure. (cms.gov) (federalregister.gov) CMS said the proposal would also require payers to report their application programming interface endpoints and usage metrics to the agency. Those application programming interfaces are the digital connectors that let one system pull data from another without faxing forms or retyping records. (cms.gov) (regulations.gov) This proposal fills a gap left by CMS’s January 17, 2024 final interoperability and prior authorization rule, which focused on non-drug items and services. Drug prior authorization was left for later after comments on the 2022 proposal and further work on technical standards. (cms.gov) (federalregister.gov) Hospital groups backed the direction of the rule. The American Hospital Association said electronic standards for drug prior authorization could help reduce delays and administrative burden for patients and clinicians. (aha.org) The proposal is not final yet. The Federal Register notice says the public comment period runs 60 days from publication, putting the deadline in mid-June 2026, before CMS decides whether to issue a final rule. (federalregister.gov)
