CMS Encourages Providers to Prepare for e-Prior Authorization

Starting January 1, 2027, certain health plans regulated by the Centers for Medicare and Medicaid Services (CMS) must implement and maintain Application Programming Interfaces (APIs) to support electronic prior authorization.

The requirements stem from regulations finalized in 2024 that also require, effective January 1, 2026, payers across Medicare Advantage, Medicaid & Children’s Health Insurance Program (CHIP) and Marketplace (Federally-facilitated Exchange) to send prior authorization decisions for medical items and services within 72 hours for expedited (urgent) requests and 7 calendar days for standard (non-urgent) requests.

CMS is encouraging health care providers to begin preparing now so they can begin submitting prior authorization requests electronically in 2027. As a first step, CMS recommends that providers talk to their EHR vendors to confirm readiness.

Access the CMS Electronic Prior Authorization webpage to get started.

Last week, CMS announced that 29 health care organizations—including health systems, electronic health record developers, physician practices, networks, and digital health developers—have signed on as early adopters in an effort to address key challenges and drive solutions ahead of electronic prior authorization 2027 requirements.

Relatedly, ACOI is advocating that Congress put the 2024 regulations in statute and expand prior authorization transparency requirements. ACOI members can contact their members of Congress through the ACOI Action Center and ask them to pass the Improving Seniors’ Timely Access to Care Act, (S. 1816 and H.R. 3514).