The clock is ticking. The CMS Final Rule (CMS-0057-F) mandating 72-hour PA turnarounds by Jan 2026 is an earthquake for payers. Here's what stands out: -Fast Timelines: Payers must return PA decisions in 72 hours (urgent) or 7 days (standard). -API Mandate: They are required to build and maintain FHIR-based APIs for PA, which forces technical standardization. -Transparency: They must provide a specific reason for any denial. The goal is to end the 'black box' of PAs and force a move away from faxes and phone calls. — As with anything, implementation will be the real test. This is not a silver bullet. A mandate to use an API doesn't guarantee the clinical criteria won't become more complex. It's very possible that payers will just get faster at denying scripts, shifting the burden from 'submission' to 'appeals.' This is a massive tailwind for automation. But providers won't just adopt the payer's portal. They will adopt their own EHR-native tools that can speak to all these new APIs and also manage the appeals process. The war for the provider workflow is just heating up. Will this CMS rule actually reduce the PA burden, or just make the 'denial' part of the process faster? #PriorAuthorization #CMS #HealthPolicy #MarketAccess #FHIR #HealthTech
Mel van Londen You are absolutely correct that automation is key, attachments are still going to be PDFs, which is an enormous time drain for nurses. My bigger concern is that payers will use AI to make decisions (against URAC standards). The human must remain in control. Does the new legislation address the use of AI?
3 days is more than enough time so not sure if there will be much change but those overloaded departments might go directly to denials instead of asking for more information from providers. Well trained MAs and nurses doing auth requests in combination with adequate documention will suffice.