Recently, the Centers for Medicare and Medicaid Services (CMS) has finalized a rule focusing on streamlining the prior authorization process. With many new changes coming into effect over the next several years, we are here to provide a breakdown of this impact below.

This new change will go into effect in 2026, requiring impacted payers to expedite urgent prior authorization decisions within 72 hours and process standard requests within seven calendar days. This ensures timely access to necessary medical care and addresses prolonged approval waiting times.

To improve communication and transparency, payers are required to provide specific reasoning for denied prior authorization decisions, regardless of the communication method used. This change targets improving providers’ ability to resubmit their requests if needed, promoting a more collaborative approach.

To foster accountability, impacted payers must publicly report certain prior authorization metrics annually on their websites. Providing stakeholders with insights into the efficiency and effectiveness of the prior authorization processes.

These new policies will go into effect on January 1, 2026, with the first set of metrics due March 31, 2026.

Impact on MIPS:

With this change, a new measure is being introduced for the MIPS Promoting Interoperability performance category and the Medicare Promoting Interoperability Program. This new measure, “Electronic Prior Authorization,” requires eligible clinicians (ECs), hospitals, and Critical Access Hospitals (CAHs) to attest to requesting prior authorizations electronically via a Prior Authorization API, using certified electronic health record technology (CEHRT).

More specifically, for MIPS ECs, this involves attesting to electronic prior authorization requests for at least one medical item or service (not including drugs) ordered during the CY 2027 performance period. Eligible hospitals and CAHs are required to do the same for at least one hospital discharge and medical item or service (not including drugs) ordered during the 2027 EHR reporting period.

As CMS continues to update the healthcare environment, having expert guidance by your side can make all the difference. Working with a CMS qualified registry, like Quantician, can help you stay up to date and get back to providing high quality care to your patients. Optimize your practices and evolve with the changing landscape as you continue to understand the complexities of these upcoming changes.

For more information on how you can stay in the know, visit www.quantician.com.