Prior authorization

CMS-0057-F prior authorization: what changes for practices in 2026 and 2027

CMS-0057-F is the federal rule, published January 17, 2024, that makes Medicare Advantage, Medicaid and CHIP, and federally facilitated exchange plans streamline prior authorization. Since January 1, 2026 most of these payers must decide urgent requests within 72 hours and standard requests within 7 calendar days, and give a specific reason for every denial. By January 1, 2027 they must offer a Prior Authorization API. Drugs are excluded.

Updated October 1, 2026

Timeline

CMS-0057-F dates at a glance

Date

What changes

January 1, 2026

Impacted payers (excluding QHP issuers on the federally facilitated exchanges) must send prior authorization decisions within 72 hours for expedited (urgent) requests and 7 calendar days for standard (non-urgent) requests.

2026

Impacted payers must give a specific reason for every denied prior authorization, however the request was sent.

March 31, 2026

First annual public report of each payer's prior authorization metrics, posted on its website.

January 1, 2027

Impacted payers must implement a Prior Authorization API, plus Provider Access and Payer-to-Payer APIs.

CY 2027

MIPS eligible clinicians begin reporting the Electronic Prior Authorization measure (CY 2027 performance period / CY 2029 payment year); eligible hospitals and CAHs with the CY 2027 EHR reporting period.

Source: CMS fact sheet, CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), January 17, 2024.

Who it covers

Which payers the rule applies to

The rule applies to impacted payers: Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the federally facilitated exchanges.

The obligations fall on those payers, not on practices. What changes for a practice is the experience on the other side: faster decisions, a stated reason when a request is denied, published payer metrics, and — from 2027 — a standard electronic route to request prior authorization. Prior authorizations for drugs are excluded from CMS-0057-F.

Not yet final

Drug prior authorization: proposed, not final

On April 10, 2026 CMS proposed a separate rule, CMS-0062-P, that would extend electronic prior authorization to drugs covered under a medical benefit beginning October 1, 2027, and require Medicaid, CHIP, and exchange plans to support electronic prior authorization for drugs under a pharmacy benefit. It is a proposal, not a final rule.

Source: CMS fact sheet, 2026 Interoperability Standards and Prior Authorization for Drugs Proposed Rule (CMS-0062-P), April 10, 2026.

For your practice

What it means day to day

Expect answers on a clock. For payers covered by the decision timeframes, a standard request with no decision after 7 calendar days, or an urgent one after 72 hours, has passed the rule's timeframe. Track submission and decision dates per request so you can see it.

Use the denial reason. Impacted payers must now say why they denied. That reason is what an appeal or a corrected resubmission is built on.

Plan for electronic submission. From 2027 these payers must expose a Prior Authorization API, and MIPS clinicians start reporting the Electronic Prior Authorization measure for CY 2027.

How RSAI helps

Prior authorization with StreamAuth

StreamAuth is Revenue Stream AI's prior authorization module. It detects when a prior authorization is required based on payer, plan type, and procedure; assembles the payer-specific clinical justification from the EHR record; submits electronically where the payer supports it; tracks status in real time; follows up automatically when information is requested or a deadline passes; and drafts appeal briefs that map the stated denial reason against the clinical record.

See StreamAuth Request a demo

Sources: CMS fact sheet, CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), January 17, 2024; CMS fact sheet, 2026 Interoperability Standards and Prior Authorization for Drugs Proposed Rule (CMS-0062-P), April 10, 2026.

This page summarizes public CMS materials for general information. It is not legal or compliance advice; confirm requirements and dates for your payers with CMS and your counsel.