Electronic Prior Auth Standards Roll Out for Medicare Advantage, More
By Phil West

Standardized electronic prior authorization will be implemented for Centers for Medicare & Medicaid Services (CMS) payers in Medicare Advantage, Medicaid, and other programs, among others, starting in the new year – potentially providing a modicum of relief for physicians.

CMS’ final rule on interoperability and prior authorization, which took effect in April 2024, requires affected payers to use application programming interfaces (APIs) – the protocols that electronic systems use to communicate with each other – that meet the technical standards referenced in the final rule. That includes Health Level Seven® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standards starting Jan. 1, 2027.

FHIR® is a commonly used, interoperability-strengthening vehicle for exchanging electronic health information, per the Office of the National Coordinator for Health Information Technology’s website.

The final rule affects:

• Medicare Advantage organizations;
• State Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service programs;
• Medicaid managed care plans;
• CHIP managed care entities; and
• Qualified health plan issuers on the federally facilitated exchanges (FFEs).

 As the new systems roll out in 2027, physicians should begin to see prior authorization requests for patients enrolled in affected plans move away from faxes and separate payer portals and into their electronic health record systems. How quickly physicians experience these improvements will depend, in part, on how quickly payers, health information technology vendors, and physician practices implement and integrate the new APIs.

The APIs must also communicate whether a payer approves, denies, or requests more information for each prior authorization request.

“It really truly is the right direction,” said Brian Bruel, MD, a member of the Texas Medical Association’s Council on Socioeconomics. “But it would be better if they could just get rid of unnecessary prior authorizations altogether.”

Given the widespread adoption of Medicare Advantage – with more than half of Medicare patients now enrolled in a Medicare Advantage plan, per the Medicare Payment Advisory Commission’s March 2026 report – TMA says the final rule has the potential to have knock-on effects on payer prior authorization processes more broadly.

Payers are also required to publicly report certain prior authorization metrics on their websites. Because the initial posting was due March 31, it is now possible to track performance for affected payers, comparing denial rates, percentages of appeals overturned, and average standard decision times.

Since this January, the final rule has also required impacted payers to send prior authorization decisions within 72 hours for expedited requests and seven calendar days for what CMS deems “non-urgent” requests. These timelines do not apply to qualified health plan issuers on the FFEs, which remain subject to separate federal timeline requirements.

Dr. Bruel notes he has not noticed appreciably faster approvals since the decision-timeline provision took effect.

“If you are seeing a patient suffering from intense pain, but you can’t do anything for them, such as an epidural the same day, because you have to get authorization, they could have to wait up to two weeks,” the Houston pain management specialist said.

Dr. Bruel says delays in approved care often require him to prescribe medications to hold patients over, curtailing his autonomy and keeping him from giving patients the option he sees as best for them.

“That’s a real-world problem that I face as a pain physician,” he said, noting that patients can also lose time from work and even require emergency department and hospital care in these scenarios, adding financial consequences to the equation.

Visit TMA’s Physician Payment Resource Center for help resolving payer issues.