Article
What changes on Jan. 1
The 2024 CMS interoperability and prior authorization final rule requires Medicare Advantage organizations, Medicaid and CHIP managed care plans, and qualified health plans on the federal exchanges to support prior authorization through standardized application programming interfaces starting Jan. 1, 2027. The goal is one consistent, standards-based approach that lets a provider’s electronic health record or practice management system work with many plans instead of a different process for each.
Through these connections, providers should be able to learn whether a service needs approval, see the documentation a plan requires, build the request from data already in the record, and receive an electronic answer: approved, denied or more information needed. Response time limits are already in force: 72 hours for expedited requests and seven calendar days for standard ones. Plans must also publicly report certain prior authorization metrics.
What does not change
The rule does not remove prior authorization or change plans’ coverage rules or medical necessity criteria. The improvement is in how information moves, not in what plans decide. In an AHA analysis published in July, the association described Jan. 1 as a milestone rather than a finish line.
Questions to ask now
The AHA is hosting a webinar with CMS and Epic on practical readiness. Leaders should push for clear answers on three fronts.
- Payers. Will electronic prior authorization be live by Jan. 1? For which products and lines of business? Is pre-launch testing available?
- Vendors. What upgrades or configuration does your EHR need? What training, testing tools and workflow support come with it?
- Internal teams. How will clinicians and staff see requirements and status updates? Which steps become electronic and which stay manual? What is the fallback if a plan is not ready?
Who should be in the room
Readiness cuts across information technology, revenue cycle, utilization management, case management, clinical operations and compliance. Without a single owner, each group may assume another is handling payer testing or staff training. Readiness will vary by payer and market, so a tracker by plan is more useful than a single go-live date.
Archive entry for Sep 7, 2026, added Nov. 11, 2026.