Prior authorization decision deadline
From 1 January 2026, Medicare Advantage, Medicaid and CHIP plans must decide an expedited prior authorization in 72 hours and a standard one in seven calendar days. Put in when you submitted it and see the date. Free, and it tells you plainly when the rule does not apply to your payer.
The rule, in its own words
“We are 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.”
“Beginning in 2026, impacted payers must provide a specific reason for denied prior authorization decisions.” The compliance date for these process requirements is 1 January 2026.
CMS Interoperability and Prior Authorization final rule (CMS-0057-F). CMS fact sheet. Read on 12 September 2026.
This is a counting tool, not legal advice, and it does not know your plan contract — which may set a shorter turnaround than the federal floor. If it came back denied for a missing authorisation, that is CO-197.
Why a date changes the call
Most authorisation chasing is a person ringing to ask whether there is an update, and a plan 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 a different conversation — it is specific, it is checkable, and the person on the other end can see the same clock you can. That is the whole value of knowing the number, and until 2026 there was no federal number to know.
What this does not tell you
- Whether your plan contract is tighter. Many are. The federal rule is a floor, not a ceiling, and a contract that promises five days beats seven.
- What your state requires. Several states set their own authorisation turnarounds by statute, and those reach commercial plans this rule does not.
- What to do about a denial. That is the appeal letter generator, and the code you will be answering is usually CO-197.
Questions
How long can an insurance company take to approve a prior authorization?
For an impacted payer under CMS-0057-F — Medicare Advantage, state Medicaid and CHIP fee-for-service, and Medicaid and CHIP managed care plans — 72 hours for an expedited (urgent) request and seven calendar days for a standard one, from 1 January 2026. QHP issuers on the Federally-facilitated Exchanges are excluded from that requirement. Ordinary commercial plans and self-funded employer plans are not covered by this rule at all: their turnaround comes from state law and from the contract.
What happens when a payer misses the prior authorization deadline?
The rule sets the timeframe; it does not hand the practice an automatic remedy. What it does give you is a date to quote. Ring on the day it passes, ask for the reference number for the delay, and keep the record — a payer asked for a reference on a missed federal deadline behaves differently from one asked "any update?"
Does the payer have to say why it denied the authorization?
Yes, for impacted payers. CMS states that beginning in 2026 impacted payers must provide a specific reason for denied prior authorization decisions. "Not medically necessary" with no policy provision attached is not a specific reason, and asking for the provision in writing is the first move in the appeal.
Is this tool free and does it store what I type?
Free, no sign-up, and nothing is stored or transmitted — the arithmetic happens in your browser. Do not type patient identifiers into it; you do not need to, and it does not ask.
Somebody has to watch these clocks every day
One deadline is a diary note. Two hundred a month is a job — submitted ahead of scheduling, chased to a decision rather than waited on, and escalated the day the deadline passes. That is what a prior authorization seat does, at $1,900 a month, full time, on your hours.
Nothing you typed into the tool above is attached to this. This form sends the three fields in it and which page it came from — that is all it can send. Or write to ops@softhomeglobal.com and skip the form entirely. What happens to it.
Next step
Somebody has to watch these clocks
A prior authorization seat submits ahead of scheduling and chases the decision to a date rather than waiting for one. $1,900 a month, full time, on your hours.
Or write to ops@softhomeglobal.com