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Win! CMS reigns in prior auth

New rules require payors to respond to urgent requests within 72 hours.
Success, high five or doctors in meeting for a strategy, goals or working in hospital for healthcare together. Man, happy woman or excited surgeons with nursing target, medical mission or teamwork
Success, high five or doctors in meeting for a strategy, goals or working in hospital for healthcare together. Man, happy woman or excited surgeons with nursing target, medical mission or teamwork

According to a rule issued by CMS on Jan. 17, 2024, starting in 2026, health plans must decide on prior authorization requests within 72 hours for an expedited request or 7 days for non-urgent appeals.

The rule also requires plans to provide a detailed rationale for a denial and include metrics on denials and approvals.

AGA and our allies in the physician community have aggressively advocated that Congress and the Administration address prior auth, which slows patient access to care and contributes to physician burnout.Ā 

The rule applies to Medicare, Medicare Advantage (MA), Medicaid, Childrenā€™s Health Insurance Plans (CHIP) and qualified health plans on the exchange.

Thank you to our advocates who called on policymakers to take action to ensure patients receive care in a timely manner.

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