Prior authorization: clarity is part of access

For a patient waiting for care, an authorization request is more than an administrative task. The team needs to know what was requested, what information is missing, and when a decision is due. Clear communication gives the patient a next step.

Know which timeline applies

Under CMS-0057-F, the 2026 decision-time requirements for impacted payers are generally 72 hours for expedited requests and seven calendar days for standard requests. This provision excludes qualified health plan issuers on federally facilitated exchanges. The rule’s prior authorization policies concern medical items and services, not drugs.

These are not universal deadlines for every payer or situation. Teams should confirm the applicable program, urgency, and any more protective requirements when reviewing a request.

Make a denial useful

Beginning in 2026, impacted payers must give a specific reason for a denied prior authorization request. CMS also requires public reporting of certain authorization metrics. The rule phases in electronic exchange requirements primarily in 2027.

In daily practice, a meaningful explanation helps distinguish missing information from a coverage or medical-necessity issue. Record the actual rationale, the supporting clinical facts, and the appropriate route for reconsideration or appeal.

Close the communication loop

Assign someone to track the request through resolution and update the patient when the plan changes. Review repeated delays with both clinical and administrative teams. A completed task in a work queue should correspond to a clear plan for the person waiting.