How long can a payer take to decide a prior authorization?

The answer changed on 1 January 2026

Until this year, "how long can they take" had no general answer. It depended on the plan document, sometimes on state law, and often on nothing enforceable at all. The CMS Interoperability and Prior Authorization final rule, CMS-0057-F, changed that for a large share of the market.

In the rule’s own words, CMS is "requiring impacted payers (excluding QHP issuers on the FFEs) to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests." The compliance date for these process requirements is 1 January 2026.

Who is an impacted payer

Medicare Advantage organisations, state Medicaid and CHIP fee-for-service programmes, and Medicaid and CHIP managed care plans. Between them that is a very large share of the authorisations a typical practice is waiting on.

Who is not: ordinary commercial plans that are not on a federal exchange, self-funded employer plans under ERISA, and — for this particular requirement — qualified health plan issuers on the Federally-facilitated Exchanges, whom the rule excludes by name. For those, the turnaround comes from the plan contract and, in several states, from state statute. Quoting a federal deadline at a payer the rule does not reach is an argument that ends the conversation, so it is worth knowing which you are dealing with before you ring.

And they have to say why

The same rule: "Beginning in 2026, impacted payers must provide a specific reason for denied prior authorization decisions." A denial that says only "not medically necessary", with no policy provision named, is not a specific reason — and asking for the provision in writing is the first move in the appeal rather than a courtesy.

Why a date changes the call

Most authorisation chasing is somebody ringing to ask whether there is an update and a representative saying it is still in review. Nothing about that call obliges anybody to do anything, which is why it can be repeated for three weeks without producing a decision.

A date changes the shape of it. "This was submitted at nine on the fourth, a decision was due on the eleventh, can I have the reference number for the delay" is specific, checkable, and visible to the person on the other end on the same screen you are looking at. That is the whole value of knowing the number — and until this year there was no federal number to know.

Work out your own date

We built a free calculator: put in when you submitted, pick expedited or standard and the kind of payer, and it gives the date and time a decision was due. It also tells you plainly when the rule does not apply to your payer, which is the part that keeps the call from going wrong.