72 hours to approve or deny. CMS just rewrote the rules on prior authorization.
Starting in 2026, health plans covering Medicare Advantage, Medicaid managed care, and ACA marketplace populations must respond to prior authorization requests within 72 hours for standard requests and 24 hours for urgent requests. Plans that miss these timelines face escalating financial penalties. Plans that maintain denial rates outside CMS-defined reasonable ranges trigger enhanced audit activity.
📊 This is the most significant structural change to prior authorization since the ACA, and its implications extend well beyond the response time requirements. The rule also mandates that health plans implement electronic prior authorization through standardized APIs, publish their prior authorization data publicly including approval and denial rates by service category and demographic group, and provide specific clinical reasons for every denial in language that providers can actually use for appeals.
The elect…
