Interoperability and Prior Authorization Final Rule Requirements — Prior Authorization and Concurrent Review Timeframes
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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.
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.
Determination Timeframe Criteria
Determination Timeframe Criteria
Timeframe requirements and permitted extensions for determinations under applicable product lines:
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)
- Deadline: 1 business day 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.
Standard Concurrent Review
- Deadline: 1 business day 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.
Expedited Prior Authorization
- Deadline: 72 hours after receipt of the request.
- Extension: May extend up to 14 additional calendar days under limited circumstances.
Implementation note
- Effective January 1, 2026, Healthfirst must notify the enrollee (and the physician or provider involved, as appropriate) of standard organization determinations no later than 7 calendar days after receiving the request; timeframe may be extended up to 14 calendar days under limited circumstances.
Coding and Decision Timeframes
| No codes listed |
Prior Authorization and Notification Requirements
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 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
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