CMS prior authorization final regulation incorporates AADA’s recommendations

The AADA advocated for these specific prior authorization reforms, which will take effect in 2026. While the regulations currently apply only to Medicare, Medicare Advantage, Medicaid, and CHIP plans and not to private, commercial, and ERISA plans, the AADA anticipates that many private health plans will adopt similar policies.

CMS accepted many recommendations advocated by the AADA, including:

• Shorter deadlines for health plans to respond to prior authorization for urgent and non-urgent requests (72 hours and seven days, respectively). The AADA supported the improved timeframes and CMS acknowledged that stakeholders, including the AADA, advocated for faster timeframes and will consider updating its policies in future rulemaking.

• Increased transparency of health plans’ use of prior authorization. Starting in 2026, impacted payers must provide a specific reason for denied prior authorization decisions as well as provide access to policies and procedures for prior authorization decisions.

• Reporting prior authorization metrics. The Academy supported the CMS requirement that payers publicly report certain prior authorization metrics, including approval/denial rates and average processing time, annually on their websites beginning in 2026.

The AADA developed a summary of CMS’s final prior authorization rule for Medicare, Medicare Advantage, Medicaid, and CHIP plans.