On January 17, the Centers for Medicare and Medicaid Services (CMS) finalized the Interoperability and Prior Authorization rule, which includes the establishment of a 72-hour prior authorization turnaround time for expedited cases and a seven-day response time requirement for standard cases applicable to Medicare Advantage plans beginning in 2026. Additionally, the rule establishes interoperability standards designed to improve the exchange of health information and prior authorization processes.

CMS establishes the electronic standardization of prior authorization (PA) through the establishment of Application Programming Interface (API) Implementation Guides (IG) for patients and providers, as well as a payer-to-payer data exchange API. This final rule will now require Medicare and Medicaid payers to:

• Allow for the exchange of patient information between payers, such as when a patient changes insurance.
• Allow for the exchange of patient data between payers and providers, including adjudicated claims and encounters data, and patient PA decisions.
• Establish a PA turnaround time requirement of seven days for standard cases and 72 hours for urgent cases.
• Include information about prior authorization (PA) decisions, including a specific reason for denials, in the patient access API.
• Publicly report certain PA metrics annually by posting them on their website.

This rule also adds a new "Electronic Prior Authorization" measure for the Merit-based Incentive Payment System (MIPS). It will be crucial for CMS to mandate that EHR vendors comply with the requirements set forth in the MIPS program so as not to punish physicians.

What’s Next: ASTRO is hopeful this will have its intended effect of increasing prior authorization transparency while at the same time reducing the burden that prior authorization has on patients, providers and payers. The prior authorization decision-making timelines will become effective January 1, 2026. The reporting of the electronic PA measure under MIPS is to be implemented by January 1, 2027.