New CMS regulations will streamline prior authorizations in some plans

The Centers for Medicare and Medicaid Services finalized a set of regulations related to prior authorizations earlier this month that AAFP and other physician organizations have advocated for years. Beginning in 2026, the rules will require Medicare Advantage plans, Medicaid managed care plans, and managed care plans in the Children’s Health Insurance Program to issue decisions on prior authorization requests within 72 hours for urgent appeals and within seven days for non-urgent appeals. They will also require plans to include specific reasons for denials, and to publicly report metrics on prior authorizations.

“The American Academy of Family Physicians applauds the Centers for Medicare and Medicaid Services for finalizing new regulations to streamline and automate prior authorization processes across payers,” AAFP President Steven Furr, MD, said in a press statement. “This marks significant progress to address care delays and the administrative burden physicians and their patients face daily.”

The rule will also require affected plans to implement an electronic prior authorization application programming interface, or API, to automate the process. That provision takes effect in 2027.

“Electronic prior authorization will help cut down on the time physicians spend requesting and appealing coverage authorization from plans, as well as provide patients with more visibility into their care,” Furr said. “However, policymakers must also address the overwhelming volume of prior authorizations that physicians must complete. Physician practices are being forced to hire dedicated staff to handle prior authorizations instead of investing in staff or tools that would enhance patient care. Instead of interfering in the decisions family physicians make in consultation with their patients, our health care system should improve access to the primary care patients need.”

Read more about the new regulations at CMS.gov.