Prior auth's big day: January 1, 2027
CMS-0057-F is the federal rule meant to turn prior auth from a fax-and-phone marathon into something closer to a brisk walk. Here's what payers owe you, and when. Mark your calendar, preferably not with a fax.
| Date | What happens | Status |
|---|---|---|
| Jan 17, 2024 | CMS publishes the final rule (CMS-0057-F). | Done |
| Jan 1, 2026 | Impacted payers (excluding QHP issuers on the FFEs) must send decisions within 72 hours for urgent and 7 calendar days for standard requests, and give a specific reason for denials. Drugs excluded. | In effect |
| Mar 31, 2026 | Initial prior authorization metrics must be publicly reported by payers. | Past due date |
| Jan 1, 2027 | Payers must implement a Prior Authorization API (covered items, documentation requirements, request/response, approve/deny-with-reason/need-more-info), plus Provider Access, Payer-to-Payer, and expanded Patient Access APIs. Exact dates vary by payer type. | Upcoming |
| CY 2027 | New "Electronic Prior Authorization" attestation measure for MIPS eligible clinicians (CY 2027 performance period / CY 2029 payment year). | Upcoming |
Who it covers
Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on the Federally Facilitated Exchanges. It doesn't apply to prior authorizations for drugs.
What it means at the front desk
Covered payers have to decide faster and actually tell you why they said no. Commercial plans outside the rule and portal-only payers will keep doing things the old-fashioned way (sigh), which is where the prior auth tools come in.