Independent practices billing Medicare Advantage, Medicaid, or ACA marketplace plans now work against a hard number: CMS requires a decision on a standard prior authorization request within 7 calendar days, half the 14 days Medicare Advantage plans previously had under their own determination rules. Expedited requests get 72 hours, and the clock started running January 1, 2026, under CMS's Interoperability and Prior Authorization Final Rule, known as CMS-0057-F.
The new deadline: 7 days, not 14
CMS finalized CMS-0057-F on January 17, 2024, and phased the requirements in over two years. The rule covers six payer categories: Medicare Advantage organizations, state Medicaid fee-for-service programs, Medicaid managed care plans, CHIP fee-for-service agencies, CHIP managed care entities, and Qualified Health Plan issuers on the federally-facilitated exchanges. The turnaround-time requirement took effect January 1, 2026. Standard requests now get a 7-calendar-day limit, down from the 14 days Medicare Advantage plans previously allowed themselves for standard organization determinations. Expedited requests must get an answer within 72 hours. CMS's own materials describe the change as cutting some payers' prior decision timeframes in half.
What payers must report, and what the first numbers show
The same rule requires payers to post prior authorization metrics on their own websites every year, with the first report due March 31, 2026. That public posting requirement gave KFF its first chance to measure how often prior authorization gets denied and how often a denial survives an appeal. In an analysis published August 13, 2026, using 2025 data, KFF found Medicare Advantage plans denied 12% of standard prior authorization requests and 10% of expedited ones. Medicaid managed care plans denied 14% of standard requests and 12% of expedited requests. ACA marketplace plans denied the most: 18% of standard requests and 16% of expedited requests.
Appeals reversed many of those denials. KFF found 67% of Medicare Advantage denials were overturned on appeal, against 47% in Medicaid managed care and 43% in the ACA marketplace. On Medicare Advantage, a denial reversed on appeal two out of three times means billing staff who skip the appeal step are leaving reimbursable claims unpaid.
| Plan type | Standard denial rate | Expedited denial rate | Appeal overturn rate |
|---|---|---|---|
| Medicare Advantage | 12% | 10% | 67% |
| Medicaid managed care | 14% | 12% | 47% |
| ACA marketplace | 18% | 16% | 43% |
Source: KFF, "Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain," August 13, 2026, 2025 data.
The 2027 API deadline
A second deadline follows on January 1, 2027. By that date, impacted payers must run three new FHIR-based APIs: a Provider Access API, a Payer-to-Payer API, and a Prior Authorization API, on top of the Patient Access API most plans already built under an earlier interoperability rule. The Prior Authorization API is meant to let a practice's EHR or practice management system submit a request and receive a decision electronically, in place of fax and payer-portal workflows for the plans that adopt it. CMS estimates the combined rule, turnaround times, public reporting, and the API build, will save the health care system approximately $15 billion over ten years, largely from staff time no longer spent on manual prior authorization work.
| Requirement | Compliance date |
|---|---|
| Standard decisions within 7 days, expedited within 72 hours | January 1, 2026 |
| First public prior authorization metrics posted | March 31, 2026 |
| Provider Access, Payer-to-Payer, and Prior Authorization APIs live | January 1, 2027 |
Source: CMS, "CMS Interoperability and Prior Authorization Final Rule CMS-0057-F," fact sheet.
A new MIPS bonus tied to electronic prior authorization
CMS is also using its physician payment program to push adoption on the provider side. Under proposed changes to the Merit-based Incentive Payment System, eligible clinicians can claim an optional Electronic Prior Authorization measure starting with the CY 2027 performance period, which sets payment for the CY 2029 MIPS payment year. The measure is a yes-or-no attestation: a clinician confirms they requested at least one prior authorization electronically through a Prior Authorization API using certified EHR technology, or claims an exclusion. CMS proposed making it worth 5 bonus points on top of what a practice already earns in the Promoting Interoperability performance category. Five points will not decide a MIPS score by itself, but it rewards practices that build the same electronic workflow the payer-side rule already requires plans to support.
Drug prior authorization is next
The requirements finalized so far apply to medical items and services, not drugs. CMS opened that gap on April 10, 2026, with a proposed rule, CMS-0062-P, that would extend similar electronic prior authorization standards to drug requests across the same six payer categories. The public comment period on that proposal closed June 15, 2026, and CMS has not yet set a final compliance date. A practice or billing company handling both medical and pharmacy prior authorizations should expect the drug side of the workflow to follow the medical side onto the same API-based track, on a later timeline.
What this means for practices and billing companies
These deadlines limit how long a decision can take and force payers to show their results in public, but nothing in the rule caps how many services require authorization in the first place. A practice that tracks its own average prior authorization turnaround against the 7-day and 72-hour ceilings, broken out by payer, will know well before each March 31 public report whether a given plan is complying. Billing companies serving several practices can build that tracking once, across every plan they touch, instead of leaving each practice to check compliance on its own.
The appeal numbers are worth checking internally, too. If a practice's own overturn rate on Medicare Advantage appeals sits well under the 67% KFF found nationally, staff may be leaving winnable appeals unfiled. The same check applies at 47% for Medicaid managed care and 43% for ACA marketplace plans. As the API deadline approaches in January 2027, the practices with the cleanest internal tracking now will have the easiest time proving which payers actually met the standard.
Sources
- CMS, "CMS Interoperability and Prior Authorization Final Rule CMS-0057-F," fact sheet
- CMS, "CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Authorization Process," press release, January 17, 2024
- KFF, "Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain," August 13, 2026
- CMS, "2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule," fact sheet, April 10, 2026
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