CMS Proposes Faster, More Transparent Prior Authorization Approvals for Payers

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The Centers for Medicare and Medicaid Services (CMS) proposed a comprehensive rule (proposed in 2026) aimed at accelerating the prior authorization process for Medicaid and Affordable Care Act (ACA) plans. This proposal expands requirements previously focused on non-drug services to include drug-related PA requests, impacting various payers such as Medicare Advantage organizations, state Medicaid/CHIP programs, and QHP issuers. Key changes include mandated response times: within 24 hours for urgent requests and 72 hours for standard requests. Furthermore, payers must publicly disclose claim denials, appeal outcomes, and decision timelines regarding drug coverage. These changes are slated to take effect on October 1, 2027, if finalized. Technically, CMS requires all impacted payers to incorporate drug coverage and documentation requirements into their existing prior authorization APIs. Crucially, the proposal mandates that all HIPAA covered entities adopt HL7 FHIR standards for prior authorization transactions. This initiative reflects CMS' ongoing efforts to curb PA delays and improve patient access to care. This regulatory push follows reports from clinicians (93% of whom believe PA delays care) and industry pledges by major payers (e.g., UnitedHealthcare, Humana) to streamline the process.