CMS Electronic Prior Authorization Requirements Take Effect January 1, 2027 for Medicare Advantage and Medicaid Managed Care

On January 1, 2027, Medicare Advantage organizations, Medicaid managed care plans, CHIP managed care entities, and federally facilitated exchange QHP issuers must support electronic prior authorization through standardized APIs under CMS's 2024 Interoperability and Prior Authorization final rule. The rule requires impacted payers to enable providers to determine prior authorization requirements, submit requests, and receive approval decisions electronically through EHR integration, using standardized HL7 FHIR-based workflows. The rule does not eliminate prior authorization or change medical necessity criteria — it standardizes the electronic exchange of prior authorization information between providers and health plans. Hospitals should engage EHR vendors and health plans now to prepare workflows, test systems, and train staff before implementation.

Managed Care