The CMS Prior Authorization Final Rule, officially known as CMS-0057-F, aims to streamline the prior authorization process and improve health information exchange. Some key points of the rule include:
- Requires payers to provide a specific reason for denied prior authorization decisions starting in 2026
- Establishes time limits for prior authorization decisions - 72 hours for urgent requests and 7 calendar days for standard requests
- Mandates that payers support electronic prior authorization on EHR systems
- Requires payers to add prior authorization information to data available via the Patient Access API