CurrentHealthfirstPolicy N/A

Interoperability and Prior Authorization Final Rule Requirements — Prior Authorization and Concurrent Review Timeframes

This document governs Healthfirst's prior authorization and concurrent review decision timeframes in accordance with the Interoperability and Prior Authorization Final Rule and applicable CMS/NYSDOH standards; it affects Healthfirst enrollees and contracted providers across the listed product lines.

Policy Summary

PayerHealthfirst

PolicyInteroperability and Prior Authorization Final Rule Requirements — Prior Authorization and Concurrent Review Timeframes

Policy CodePolicy N/A

Change TypeMaterial timeline revision

Effective DateN/A

Next Review Date2026-05

Key ActionNotify the enrollee and provider of standard determinations no later than 7 calendar days after receiving the request (effective Jan 1, 2026).

SourceLink

POLICY UPDATE CHANGES

Standard authorization decision timeframe changed from 14 calendar days to 7 calendar days after receipt of the request.

Beginning January 1, 2026, Healthfirst must notify the enrollee and provider of standard determinations no later than 7 calendar days after receiving the request with possible extension up to 14 calendar days.

7dmaximum standard decision notification timeframe

14dpossible extension to decision timeframe

3bdStandard Prior Authorization (after info)

1bdConcurrent review / Inpatient rehab (after info)

72hExpedited Prior Authorization

Determination Timeframe Criteria

Timeframe requirements and permitted extensions for determinations under applicable product lines:

Applies to: Medicaid Managed Care, HARP (Personal Wellness Plans), Senior Health Partners (SHP), CompleteCare (MAP), and Child Health Plus (CHPlus).

Standard Prior Authorization

Deadline: 3 business days after all necessary information is received, but no later than 7 calendar days after receipt of the request.
Extension: May extend up to 14 additional calendar days under limited circumstances.

Prior Authorization for Inpatient Rehabilitation Services (after an inpatient hospital admit)

Policy Summary

PayerHealthfirst

PolicyInteroperability and Prior Authorization Final Rule Requirements — Prior Authorization and Concurrent Review Timeframes

Policy CodePolicy N/A

Change TypeMaterial timeline revision

Effective DateN/A

Next Review Date2026-05

Key ActionNotify the enrollee and provider of standard determinations no later than 7 calendar days after receiving the request (effective Jan 1, 2026).

SourceLink

On This Page

Coding and Decision Timeframes

Not applicablemixed

No codes listed

Decision timeframes

Standard Prior Authorization3 business days after all necessary information is received, but no later than 7 calendar days after receipt of the request; possible extension up to 14 calendar days

Prior Authorization — Inpatient Rehab (post-admit)1 business day after all necessary information is received, but no later than 7 calendar days after receipt; possible extension up to 14 calendar days

Standard Concurrent Review1 business day after all necessary information is received, but no later than 7 calendar days after receipt; possible extension up to 14 calendar days

Expedited Prior Authorization72 hours after receipt of the request; possible extension up to 14 calendar days

Prior Authorization and Notification Requirements

Prior Authorization

Standard Determination Notification Requirement

Healthfirst must notify the enrollee (and the physician or provider involved, as appropriate) of its standard determination no later than 7 calendar days after receiving the request. Under limited circumstances, Healthfirst may extend this timeframe by up to 14 calendar days.

Applies to standard organization determinations for services or items beginning January 1, 2026.
Notification must go to the enrollee and the physician or provider involved, as appropriate.
Extension of up to 14 calendar days permitted only under limited circumstances per regulatory requirements.

Prior Authorization

Prior Authorization and Concurrent Review Timeframes — Provider Obligations

Healthfirst will make determinations and provide notice within the following timeframes depending on program and request type: Standard Prior Authorization — 3 business days after all necessary information is received, but no later than 7 calendar days after receipt of the request (extension up to 14 days permitted). Prior Authorization for Inpatient Rehab Services after an inpatient hospital admit — 1 business day after all necessary information is received, but no later than 7 calendar days after receipt of the request (extension up to 14 days permitted). Standard Concurrent Review — 1 business day after all necessary information is received, but no later than 7 calendar days after receipt of the request (extension up to 14 days permitted). Expedited Prior Authorization — 72 hours after receipt of the request (extension up to 14 days permitted).

Programs covered include Medicaid Managed Care, HARP, SHP, CompleteCare (MAP), and Child Health Plus (CHPlus).
Timeframes follow the Interoperability and Prior Authorization Final Rule and applicable state/federal regulations.

Key Definitions

Interoperability and Prior Authorization Final Rule

Federal ruleInteroperability and Prior Authorization Final Rule: changes standard authorization decision timeframe from 14 calendar days to 7 calendar days after receipt (42 C.F.R. §§ 422.568(b)(1)(ii), 438.210(d), 42 CFR 457.495(d)(2)(i))

ApplicabilityCMS and NYSDOH utilize this federal 7-calendar-day standard for certain prior authorization and concurrent review requests

Effective scopeApplies to Healthfirst determinations referenced in this policy

Standard Prior Authorization (definition)

DefinitionA non-expedited prior authorization request for covered services where determination is made within the standard timeframe: 3 business days after all necessary information is received but no later than 7 calendar days after receipt

ExtensionMay be extended by up to 14 calendar days under limited circumstances

Applies toMedicaid Managed Care, HARP, SHP, CompleteCare (MAP), and Child Health Plus (CHPlus)

Expedited Prior Authorization (definition)

DefinitionA request requiring faster determination to be completed within 72 hours after receipt of the request

ExtensionMay be extended by up to 14 calendar days under limited circumstances

ContextUsed for urgent requests under Medicaid Managed Care, HARP, SHP, MAP, and CHPlus timeframes