CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) implementation for NYS Medicaid/Elderplan
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Describes the CMS Interoperability and Prior Authorization Final Rule implementation for NYS Medicaid/Elderplan effective January 1, 2027, including revised prior approval determination timelines and provider enrollment encouragement.
Replaces the existing 21-day prior approval determination timeframe with new standard and expedited timelines.
Introduces two PA request types: standard (7 days with possible 14-day extension) and expedited (72 hours).
Prior Authorization Determination Criteria
Prior Approval determination criteria and process
Prior approval requests are processed as Standard or Expedited; determinations and procedural steps follow the timelines and operational guidance below.
Standard PA timing
- Determination made within 7 days of receipt of the request.
- If more information is required, the Standard request may be extended one time for an additional 14 days; a determination will be made on or before the 14th day of the extension.
- Failure to submit requested information within these timelines will result in a PA denial.
Expedited PA timing
- Determination made within 72 hours of receipt of the request.
- If the request does not meet the definition of an expedited PA, it will be converted to a Standard request (and processed under Standard timelines).
Provider enrollment and submission channels
- Providers are encouraged to enroll in ePACES and eMedNY eXchange to enable real-time claim submission, eligibility verification, and prior approval requests.
Timelines and Code/Enrollment References
| No codes listed |
Provider Enrollment, Submission Channels, and Risk Notices
Enroll in ePACES and eMedNY eXchange
Providers are encouraged to enroll in ePACES and eMedNY eXchange to enable real‑time claim submission, eligibility verification, and prior approval request workflows. Instructions to enroll in ePACES are provided in the source guidance.
Prior Approval timelines and denial risk
Prior Approval requests are classified as Standard or Expedited with specific determination timelines; failure to provide requested information within the stated timelines will result in denial.
- Standard: determination within 7 days of receipt; may be extended an additional 14 days if more information is needed, with a determination on or before the 14th day of the extension.
- Expedited: determination within 72 hours of receipt; if the request does not meet the expedited definition it will be converted to a standard request.
Prior Approval Types
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