CMS Proposes Tighter Prior Authorization Timeframes for Drugs, But Experts Say Fragmentation and Transparency Gaps Remain

CMS has proposed a new rule that would dramatically shorten the timeframes in which federally regulated payers must respond to prior authorization requests for prescription drugs, while also mandating greater transparency around denial decisions. The proposed rule, issued April 14, would require urgent requests to be answered within 24 hours, expedited requests within 72 hours, and standard requests within 7 days. If finalized, impacted payers would need to comply by October 1, 2027.

The rule builds on CMS's 2024 prior authorization reforms, which established a 72-hour timeframe for expedited requests and 7 days for standard requests. The 2026 proposal tightens those windows further and extends requirements to Qualified Health Plan (QHP) issuers on the federal marketplace, which were excluded from the shortened timeframe requirements in the 2024 rule.

"This proposed rule would reduce the burden of prior authorization by shortening the decision timeframes in which payers must make prior authorization decisions, and requiring greater transparency around denials of care," said Amanda Myers, MD, clinical assistant professor at the University of Chicago Pritzker School of Medicine, rheumatologist at Endeavor Health, and chair of the ACR's Government Affairs Committee.

Industry Pledge Shows Mixed Results

The CMS proposal arrives against a backdrop of ongoing industry efforts to address prior authorization burdens. Last year, HHS and dozens of health insurers announced an industry pledge to streamline and reduce prior authorization. According to America's Health Insurance Plans (AHIP (搜索)搜索该公司), that pledge has led to an 11% reduction in prior authorizations "across a range of medical services," translating to approximately 6.5 million fewer prior authorizations.

AHIP (搜索)搜索该公司 also announced that participating health insurers will standardize the process for submitting electronic prior authorization requests for most services, including imaging services like CT scans and MRIs and orthopedic surgeries, spanning Medicare Advantage, commercial coverage, and Medicaid managed care.

Despite these reported gains, many healthcare professionals remain skeptical. A recent AMA survey of 1,000 physicians showed that only 33% believe the industry pledge will make a meaningful difference. Shari M. Erickson, MPH, ACP Chief Advocacy Officer and Senior Vice President of Governmental Affairs and Public Policy, told Healio: "I have honestly not heard from a lot of members that they've seen an impact in their practices at this point."

Fragmented Processes Persist Across Insurers

A recent Annals of Internal Medicine study found that prior authorization rules remain inconsistent among commercial insurers. Study co-author Aya Zaari Jabri, MS, from Stanford University, and colleagues wrote that "for approval of a prior authorization for medical and surgical services, Aetna only required a site-of-service review, while UnitedHealthcare used this and two other requirements." The researchers noted that "across all Healthcare Common Procedure Coding System codes, none of the insurers used the same criteria to require prior authorization or the same requirements to obtain prior authorization."

This fragmentation persists despite the industry pledge's intent to improve prior authorizations, with Jabri and colleagues concluding the pledge does nothing to eliminate these inconsistent processes.

Patient Impact and Access to Care

The human toll of prior authorization delays is substantial. A 2025 analysis from The Commonwealth Fund showed that 21% of U.S. working-age adults with private health insurance were denied coverage for medical care recommended by a physician in the past year. Among those denied, 41% said it led to delayed care, 28% said it worsened a health problem, and 61% said the denial caused anxiety and worry. Just half of those denied care appealed it, "citing uncertainty over their right to do so and whether it would make a difference if they did, as well as confusion about who to contact."

For patients with rheumatic and autoimmune diseases, the stakes are particularly high. Myers emphasized that "patients with rheumatic and autoimmune diseases require timely care in order to prevent severe inflammatory responses and permanent organ damage. Even brief delays in care can result in significant worsening of symptoms leading to decreased quality of life and disability."

ACR Calls for Stronger Transparency and Denial Standards

In a letter to CMS Administrator Mehmet Oz dated June 15, ACR President William F. Harvey, MD, MSc, FACR, commended the proposed changes while detailing several areas where the organization believes the rule should go further.

Regarding the requirement that payers provide specific reasons for denials, the ACR letter states: "We urge CMS to provide further detail regarding what constitutes a 'specific reason' for a coverage denial. Vague denial reasons like 'medical necessity not met' or 'does not meet plan criteria' do not provide sufficient information." Myers added that "denial criteria should be actionable and provide a clear path forward."

The ACR also urged CMS to require specialty-level disaggregation in reporting and to mandate that payers publish approval criteria, allowing physicians, patients, and advocates to compare payers' prior authorization behavior with their stated criteria.

Coverage Gaps: State-Based Exchanges and Medicare Part D

The proposed rule extends interoperability and transparency requirements to Medicare Advantage, Medicaid, CHIP, and QHP plans on the federal marketplace, but leaves out QHP issuers on state-based exchanges and Medicare Part D plans. The ACR is urging CMS to close these gaps.

For state-based exchanges that use the HealthCare.gov platform for enrollment but handle their own QHP certification, the ACR suggests CMS could condition continued access to the federal platform on meeting the new requirements. Regarding Medicare Part D, Myers noted that without inclusion, "practices would have to continue to fax paperwork or manually document in a separate portal when requesting prior authorization for Part D drugs, thereby maintaining the administrative burden the rule intends to eliminate."

AI and the WISeR Model

CMS is also testing the use of artificial intelligence for processing prior authorization claims through the Wasteful and Inappropriate Service Reduction (WISeR) Model, a pilot program launched in six states on January 1. However, a report released by Sen. Maria Cantwell, D-Wash., showed that patients' wait times for procedures under WISeR are two to four times longer due to authorization delays. According to Erickson, patients in the pilot states are going "from 1 to 2 days for quick prior authorization turnaround and 3 to 5 days for standard prior authorization to up to 10 to 15 days."

"We feel strongly that you need some level of physician oversight if you are using electronic methods to try to conduct prior authorizations or reduce the need for prior authorization," Erickson said. "There's certainly interest in making things more automated and speedier, but at the same time, it needs to be done appropriately from a clinical perspective."

ACP has previously called on health insurers to "set clear and measurable benchmarks for improvement" and has long advocated that physicians performing well on outcome measures should be exempted from prior authorizations. Erickson noted that Sen. Sheldon Whitehouse, D-R.I., "has reintroduced the Prior Authorization Relief Act, which would eliminate prior authorizations from physicians in value-based payment programs," and that a number of states are pursuing their own prior authorization reform efforts.