CMS Final Rule on Prior Authorization Reforms Save

Prior authorizations and paperwork are killing medical providers; the good news is that a new CMS rule may lessen the burden.

The Centers for Medicare & Medicaid Services (CMS) has announced that they have finalized the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), designed to improve prior authorization processes and reduce burden on patients, providers, and payers, with a resultant $15 billion of estimated savings over ten years.

“When a doctor says a patient needs a procedure, it is essential that it happens in a timely manner,” said HHS Secretary Xavier Becerra.

CMS Administrator Chiquita Brooks-LaSure said, “Increasing efficiency and enabling health care data to flow freely and securely between patients, providers, and payers and streamlining prior authorization processes supports better health outcomes and a better health care experience for all.”

While prior authorization may ensure the necessity of medical services, the process has becom an obstacle to necessary patient care when providers must navigate complex and widely varying payer requirements or face long waits for prior authorization decisions.

This final rule establishes requirements for certain payers to streamline the prior authorization process. Beginning primarily in 2026, impacted payers will be required to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests for medical items and services.

For some, this new timeframe for cuts current decision timeframes in half.  Moreover, the rule requires all impacted payers to include a specific reason for denying a prior authorization request, which will help facilitate resubmission of the request or an appeal when needed. Finally, impacted payers will be required to publicly report prior authorization metrics.

The rule also requires a more efficient electronic prior authorization process between providers and payers by automating the end-to-end prior authorization process. 

Also, see Medscape coverage - New Federal Prior Auth Rule Will Reduce Doctors' Burden, Improve Patient Care, Groups Say

The final rule is available to review here: https://www.cms.gov/files/document/cms-0057-f.pdf - PDF.

The fact sheet for this final rule is available here: https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f.