Prior authorization timelines and information-request timing

For electronic requests: carriers must make determinations within 3 calendar days for standard requests and within 1 calendar day for expedited requests; if more information is needed, the carrier must request additional information within 1 calendar day of submission. For nonelectronic requests: carriers must make determinations within 5 days for standard requests (request additional information within 5 days) and within 2 days for expedited requests (request additional information within 1 day). If the carrier still lacks sufficient information within any timeframe, it may set a specific reasonable additional timeframe and must communicate that additional information request and timeframe to both the provider and the enrollee.

• Electronic standard determination: within 3 calendar days (excluding holidays).
• Electronic expedited determination: within 1 calendar day.
• If more info needed for electronic requests: request additional information within 1 calendar day.
• Nonelectronic standard determination: within 5 days; request additional information within 5 days if needed.
• Nonelectronic expedited determination: within 2 days; request additional information within 1 day if needed.
• If still insufficient information, carrier may set a specific reasonable additional timeframe and must communicate it to provider and enrollee.

API / IEP automation requirement and enforcement dates

Carriers are required to automate prior authorization requests and determinations via an API or interoperable electronic process (IEP). The initial API upgrades must support health care service prior authorizations beginning January 1, 2026, and prescription drug prior authorizations beginning January 1, 2027.

• API/IEP for health care service prior authorizations enforceable starting Jan 1, 2026.
• API/IEP for prescription drug prior authorizations enforceable starting Jan 1, 2027.

Communication standards and clinical review criteria availability

Carriers must describe prior authorization requirements in detailed, easily understandable language, make current requirements and written clinical review criteria electronically available to providers and facilities upon request, and base requirements on peer-reviewed, evidence-based clinical review criteria. Carriers must ensure criteria accommodate new and emerging information related to race, gender, and underserved populations and evaluate and update clinical review criteria at least annually if necessary.

• Describe prior authorization requirements in detailed, easily understandable language.
• Provide current prior authorization requirements and written clinical review criteria electronically to providers and facilities upon request.
• Base requirements on peer-reviewed, evidence-based clinical review criteria.
• Ensure clinical review criteria accommodate new and emerging information related to Black and Indigenous people, other people of color, gender, and underserved populations.
• Evaluate and update clinical review criteria at least annually, if necessary.