August 15, 2025
Ensure review systems and data reporting are ready
The Centers for Medicare & Medicaid Services (CMS) Final Rule CMS-0057-F, Interoperability and Prior Authorization, introduces reforms to streamline and modernize the prior authorization process across various federal health programs.1
These changes affect how independent practice associations (IPAs) that are delegated utilization management responsibilities process prior authorization (PA) requests effective January 1, 2026.
Highlights of the Rule
The Rule mandates that payers and delegated entities:
- Provide timely decisions (within 72 hours for urgent and 7 calendar days for standard requests).
- Implement a prior authorization Application Programming Interface (API) to streamline and automate the process (refer to additional details below about APIs).
- Publicly report prior authorization metrics.
- Improve data sharing between payers, members, physicians and other providers.
Note, the above is not an all-inclusive list of requirements.
New PA timelines
Refer to the following chart to find out how PA timelines for standard requests will change. The timeline for urgent or expedited requests will remain the same.
| Type of prior authorization | Current timeline | Timeline as of January 1, 2026 |
|---|---|---|
|
Standard |
14 calendar days |
7 calendar days |
How this affects your operations and systems
- Delegated entities will need to streamline their internal review processes, possibly by adopting automation or increasing staffing, to comply with the shortened turnaround times.
- Health plans must publicly report prior authorization metrics. Delegated entities should continue to provide detailed data on their prior authorization activities to support this reporting.
- Delegation agreements may need to be updated to reflect the new regulatory requirements, including performance standards, data sharing protocols and compliance monitoring.
Goals of the changes
- Improved timeliness: The shortened timeline is designed to reduce delays in patient care caused by lengthy authorization processes.
- Administrative efficiency: By mandating faster responses, the CMS aims to alleviate administrative burdens on physicians and other providers, and improve patient outcomes.
- Technology integration: The rule also mandates the implementation of prior authorization APIs by January 1, 2027, to automate and streamline the submission and tracking of requests.
View the Final Rule online
Learn more about the Final Rule on the CMS website at bit.ly/4kAqJiW.
Additional information
Relevant sections of the Wellcare Provider Manual will be revised to reflect the information contained in this update as applicable. The manual is available online at www.wellcare.com/California/Providers/Medicare.
If you have questions regarding the information contained in this update, contact 866‑999‑3945
