Starting January 1, 2026, the Centers for Medicare & Medicaid Services (CMS) will require faster turnaround times for all prior authorization (PA) requests:
- Standard PA requests must be completed within 7 calendar days. In some cases, an extension of up to 14 calendar days may apply.
- Expedited/Urgent requests must be completed within the lesser of 72 hours or the current business-day turnaround time.
To meet these timelines, please submit all required clinical information with your initial request.
Complete clinical submissions include:
- Diagnosis
- Patient history and current condition
- Treatment plan and interventions
- Relevant diagnostic tests
Tips to avoid delays:
- Response times are faster when complete clinicals are included with the request.
- Incomplete submissions may result in denial due to insufficient documentation
- Use the secure Availity portal for quicker submission and review
Resources:
For questions, please contact your provider experience representative or reach out to the PR general mailbox at: ncproviderrelations@wellcare.com.
