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Interoperability and Prior Authorization Final Rule Deadline

The Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization final rule (CMS-0057-F) was published on February 8, 2024. The rule established that, beginning January 1, 2026, state Medicaid and Children's Health Insurance Program (CHIP) fee-for-service (FFS) programs send prior authorization decisions within established timeframes: 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests. When prior authorizations are denied, the reason for the denial must be communicated to providers.

As acknowledged during the November 2024 Medicaid & CHIP all-state call, CMS recognizes unique challenges and extenuating circumstances that may hinder the ability of state Medicaid and CHIP agencies to effectively implement these timeframes by January 1, 2026.

1. CMS will work with state Medicaid and CHIP FFS programs that may be unable to meet the new prior authorization decision timeframes compliance date in 2026. Those states should email their Medicaid state lead and/or CHIP project officer before April 1, 2025, to briefly: Identify extenuating circumstance(s) and unique challenges (see 11/2024 all state, slide # 21 and 24 for examples).
2. Explain why the circumstantial challenges make a delayed implementation unavoidable.
3. Identify a target compliance date for implementation and discuss their extenuating circumstances.

Once received, CMS may seek discussion to further clarify the state’s unique circumstances.