New CMS Interoperability & Prior Auth Final Rule Effective in 2026

On January 1, 2026, the first phase of the Centers for Medicare & Medicaid (CMS) Interoperability and Prior Authorization final rule (CMS – 0057-F) will go into effect. The remaining changes will go into effect January 1st, 2027. This final rule will improve the electronic exchange of healthcare data and streamline processes related to prior authorization through new requirements.  

Key provisions that will go into effect for payers include:

  • New API Use Metrics: Impacted payers will annually report metrics in the form of aggregated, de-identified data to CMS about patient use of the Patient Access API.
  • Prior Authorization Decision Timeframes: Certain payers will now be required to send standard prior auth decisions within 7 calendar days and expedited PA decisions within 72 hours.
  • Payers must provide a specific reason for denial.
  • Impacted payers are required to report certain metrics about their PA processes on a public website on an annual basis, including percent of PAs approved, denied, approved after appeal, and average time between submission & decision.

CMS is encouraging stakeholders to learn more about what it means for patients, payers and providers here.

Additional Resources

For a more comprehensive description of the CMS Interoperability and Prior Authorization Final Rule, visit the Federal Register.