What it means for you
Since January 2026, Medicare Advantage, Medicaid, and CHIP generally have 7 calendar days to decide standard requests and 72 hours for urgent ones. Limited extensions are allowed. Denials must give a specific reason.
Who benefits: People in Medicare Advantage and in Medicaid and CHIP who need prior approval for care; nearly 53 million requests were submitted to Medicare Advantage insurers in 2024, according to KFF.
Many health plans make your doctor ask permission before you can get a test, a procedure, or other care. Under this federal rule, Medicare Advantage insurers and Medicaid and CHIP programs generally have to answer standard requests within 7 calendar days and urgent requests within 72 hours. Limited extensions of up to 14 additional calendar days are allowed under program-specific conditions. Before the rule, Medicare Advantage plans and Medicaid managed care plans could take up to 14 days on a standard request.
If an insurer or program says no, it now has to give a specific reason, so you and your doctor know what to fix or appeal. That matters: in 2024, KFF found that more than 80% of the Medicare Advantage denials that were appealed got overturned. These insurers and programs also have to post yearly numbers on how often they approve and deny requests and how long they take.
You don’t need to do anything. The deadlines and the denial-reason rule began January 1, 2026. Drugs aren’t covered by these process rules, and the 7-day and 72-hour deadlines don’t apply to plans on the federal marketplace. Electronic systems that let patients access prior-approval information and providers submit requests are generally due beginning January 1, 2027.
The Centers for Medicare & Medicaid Services finalized the rule in January 2024 under Administrator Chiquita Brooks-LaSure and Health Secretary Xavier Becerra. The rule remained in force under the next administration. In May 2026, CMS Administrator Mehmet Oz said affected payers must meet its deadlines.
Health careSeniors
Sources
- CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheetCenters for Medicare & Medicaid Services, January 17, 2024
- CMS finalizes rule to expand access to health information and improve the prior authorization processCenters for Medicare & Medicaid Services, January 17, 2024
- Advancing Interoperability and Improving Prior Authorization Processes (final rule)Federal Register, February 8, 2024
- Moving prior authorization into the 21st centuryCenters for Medicare & Medicaid Services, May 5, 2026
- Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024KFF, January 28, 2026
How we checked this
Drafted by Claude Opus 5.5 (Anthropic) on November 11, 2026. Checked against its sources by GPT-5.6-sol (OpenAI) on November 11, 2026, which corrected it. Confirmed the rule, dates, scope, officials, KFF figures, and current status. Qualified the deadlines to account for permitted extensions and clarified what the 2027 electronic systems must do.
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