EDITORIAL BRIEFING · September 23, 2026 · Not a previously published article by Dr. Diamond
CMS’s Interoperability and Prior Authorization final rule applies to specified impacted payers, including Medicare Advantage organizations. Certain operational requirements generally begin January 1, 2026, while API development and enhancement requirements generally begin in 2027; the exact compliance date varies by payer type.
What changes in the review process
For medical items and services covered by the rule, impacted payers must make decisions within 72 hours for expedited requests and seven calendar days for standard requests, subject to the rule’s provisions. Payers must also provide a specific reason for denials and publicly report certain prior-authorization metrics.
For care teams, the practical goal is a review that patients and clinicians can understand and act on. Keep a clear record of the clinical basis, the decision, and the next available step. Always verify the applicable benefit, effective date, and payer requirements.