Reed Smith Client Alerts

Key takeaways

  • A recent final rule outlines new rules for prior authorization and interoperability requirements impacting Medicare Advantage, Medicaid, CHIP, and Qualified Health Plans
  • Beginning in 2026, payors will have to comply with time limit requirements on responses to prior authorization requests
  • By 2027, payors must implement API technology to automate prior authorizations and exchange information with patients, providers, and other payors

On January 17, 2024, Centers for Medicare & Medicaid Services issued a final rule that places significant new requirements on impacted payors regarding the process and timing of prior authorizations. Starting in 2026, Medicare Advantage (MA) organizations, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers will be required to send prior authorization decisions within 72 hours for urgent requests and seven days for standard requests. For some payors, this requirement may cut current decision timeframes in half. Payors also must articulate a specific reason for denying a prior authorization request. Payors are given the choice of how to communicate their denial: by portal, fax, email, mail, or phone.