Prior authorization
Prior authorization timeframes under CMS-0057-F: who must decide in 72 hours or 7 days
Prior authorization timeframes under CMS rule CMS-0057-F require covered payers to send decisions within 72 hours for expedited requests and 7 calendar days for standard requests. The rule names Medicare Advantage organizations, state Medicaid and CHIP programs, Medicaid managed care plans and CHIP managed care entities. Qualified health plan issuers on the federal exchanges are left out of the timeframes, and the rule does not apply to prior authorization decisions for drugs. This is general information, not legal advice. Review your payer contracts and the rules where you practice with your compliance advisor.
Published by OffshoreMeds. Facts last checked October 10, 2026. How we check our numbers.
Who is covered
The payers the rule names
| Payer type | Decision timeframes apply? | What the fact sheet says |
|---|---|---|
| Payer type: Medicare Advantage organizations | Decision timeframes apply?: Yes | What the fact sheet says: Named as an impacted payer. |
| Payer type: State Medicaid and CHIP fee-for-service programs | Decision timeframes apply?: Yes | What the fact sheet says: Named as an impacted payer. |
| Payer type: Medicaid managed care plans | Decision timeframes apply?: Yes | What the fact sheet says: Named as an impacted payer. |
| Payer type: CHIP managed care entities | Decision timeframes apply?: Yes | What the fact sheet says: Named as an impacted payer. |
| Payer type: Qualified health plan issuers on the federally facilitated exchanges | Decision timeframes apply?: No | What the fact sheet says: Named as impacted for other provisions, but excluded from the decision timeframes. |
The fact sheet’s list does not name other commercial plans, such as employer-sponsored plans. Their prior authorization terms sit in each plan’s own contract and in state law. Source: CMS fact sheet on rule CMS-0057-F.
The rule
What it requires, and from when
- Decision timeframes. 72 hours for expedited (urgent) requests and 7 calendar days for standard requests, for impacted payers other than qualified health plan issuers on the federal exchanges.
- A reason for each denial. Beginning in 2026, an impacted payer must give a specific reason for a denied prior authorization decision, whatever method was used to send the request. The payer may reply by portal, fax, email, mail or phone.
- Public metrics. Impacted payers must post certain prior authorization metrics on their websites each year, with the first set due by March 31, 2026.
- APIs later. The operational provisions above generally began on January 1, 2026. Payers have until compliance dates generally beginning January 1, 2027 to build the interoperability APIs.
- Drugs are out. The fact sheet says the rule’s policies do not apply to prior authorization decisions for drugs. The clocks that do apply to drugs are on the prior authorization for drugs page.
- Clinicians. The rule also adds an Electronic Prior Authorization measure to the Promoting Interoperability category of MIPS for eligible clinicians.
In practice
What the rule means for prior authorization work
- Record the payer type, whether the request was expedited or standard, and the date and method of submission. Those three facts show which clock applies.
- When a denial arrives without a specific reason, ask the payer for the reason the rule requires, and keep the reply with the request.
- Keep drug requests and plans outside the list on a separate track, because the rule does not set their timeframes.
- Electronic handling is still uneven: medical plan adoption of fully electronic prior authorization was 40% in the 2025 CAQH Index.
The work itself, from checking whether a plan requires authorization to tracking pending requests, is covered on the prior authorization staff page. A denied or late request also runs against the filing deadlines in timely filing limits for medical claims, and coverage problems found before the visit are the job of insurance eligibility verification staff. This is general information, not legal advice. Review your payer contracts and the rules where you practice with your compliance advisor.
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Related guides
- Prior authorization staff
Staff who prepare, submit and track prior authorizations, with the clinical line kept where it belongs.
- Denial management staff
Appeals, A/R follow-up and root-cause work, measured against published denial-rate benchmarks.
- Insurance eligibility verification staff
Coverage, benefits, authorization and patient-cost checks done before the visit, not after the denial.
- Timely filing limits for medical claims
The federal caps, examples from Cigna, Aetna, Texas Medicaid and Illinois Medicaid, and how to find and track the limit that applies.
- Prior authorization for drugs
The Part D and Medicaid clocks that apply to drug requests, the electronic standards and what staff track.
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