Reason on every denial
- Applies regardless of how the request was sent [1]
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Insight · Prior authorization and payer intelligence
Payer prior authorization metrics are now public: what the postings must contain and how to use them
Short answer: since March 31, 2026, MA organizations, Medicaid and CHIP programs and exchange issuers must post nine prior-authorization measures on their own websites. Turn a payer’s own approval, denial and turnaround figures into deadlines and denial defenses.
CMS-0057-F · 42 CFR 422.122(c)
72 hours expedited · 7 days standard
Prior Authorization API · Jan 1, 2027
Posted on the payer site, not at CMS
Edition
Insight · Oct 2026
Focus
Prior auth metrics
Payers
MA · Medicaid · CHIP · QHP
Metric
9 measures
Effective date
Mar 31, 2026
Length
6 min read
Six dates, two already passed
Operational provisions from January 1, 2026, APIs from January 1, 2027 [2] [3]; impacted payers: MA, Medicaid and CHIP, exchange QHP issuers [2].
- 1Jun 2025Payer pledge: real-time approvals by 2027 [4]
- 2Jan 1, 202672-hour and 7-day decision clocks; reason on every denial
- 3Mar 31, 2026First public metrics posting, covering 2025
- 4Jan 1, 2027Prior Authorization, Provider Access, Payer-to-Payer APIs
- 5CY 2027Electronic Prior Authorization measure, MIPS clinicians and hospitals
- 6Mar 31, 2027Second posting, covering 2026
Decision clocks
72 hours expedited, 7 calendar days standard [2]
Public postings
Nine measures, contract level, by March 31
APIs
Approval with end date, denial with reason, or more-information request [1]
Operational provisionsAnnual postingsAPI provisions
The nine measures an MA organization must post, 42 CFR 422.122(c)
Previous year, excluding drugs, contract level, by March 31 [1]; parallel provisions for the other payers.
| # | Measure | Aggregation |
|---|---|---|
| 1 | A list of all items and services that require prior authorization | Contract level |
| 2 | Percentage of standard requests approved | All items and services |
| 3 | Percentage of standard requests denied | All items and services |
| 4 | Percentage of standard requests approved after appeal | All items and services |
| 5 | Percentage of requests where the review timeframe was extended and the request approved | All items and services |
| 6 | Percentage of expedited requests approved | All items and services |
| 7 | Percentage of expedited requests denied | All items and services |
| 8 | Average and median time from submission to determination, standard requests | All items and services |
| 9 | Average and median time from submission to decision, expedited requests | All items and services |
What the nine measures cover, and the clocks behind them
Nine measures by type; two decision clocks
Approval and denial ratesmeasures 2, 3, 6, 7
444% of nine
Turnaround, average and medianmeasures 8, 9
222%
Reversals and extensionsmeasures 4, 5
222%
Services listmeasure 1
111%
01234 measures
Expedited clocknot exchange issuers
72 hours43% of standard
Standard clockcalendar days
7 days168 hours
02467 days
Rates and listsTime and reversalsDecision clocks
What else the rule fixes in writing
How to use the postings: what each figure tells the denial team
The figures sit on each payer’s website, replaced every March: collect with URL and date, compare with your log, use as the follow-up trigger, bring to renewal.
| Posted figure | If it is high | Worklist consequence |
|---|---|---|
| Standard denial percentage | More CARC 197 and 50 lines | Pre-visit check for every service on the payer’s list |
| Approved after appeal percentage | First denials often reversed | Appeal by default; shorter time to first appeal |
| Timeframe extended and approved percentage | Payer buys time | Follow up at the median, not the regulatory maximum |
| Average well above median turnaround | Long tail of slow decisions | Daily follow-up past the median |
| Expedited denial percentage | Urgent requests refused often | Urgency criteria at intake; same-day escalation |
In Work Genie the posted figures sit beside the authorization ledger, so a CARC 197 line from a payer that often reverses ranks higher for appeal; see the denial worklist white paper and the Denial Prediction Engine.
Takeaway
The payer has now told you, in its own numbers, how often it says no, how often it reverses itself on appeal, and how long it takes. That is a negotiating document.
Four moves before the March 2027 postings
Build the payer metrics registerPayer, contract, URL, posting date, nine figures, your own turnaround.
Open a request-to-decision log from todayPlan, standard or expedited, sent, decided; to check the March 2027 postings against.
Ask payers and your PM vendor, in writingHow you connect to the Prior Authorization API on January 1, 2027 [1].
Tag authorization CARCs by payer in the worklistCompare posted rates with what you see. See the clean claim rate guide, the Work Genie Brief, the RCM Command Center and the free denial audit.
Frequently asked questions
Which payers must publish prior authorization metrics?
Under CMS-0057-F the impacted payers are Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities and Qualified Health Plan issuers on the federally facilitated exchanges. Commercial employer plans outside the exchanges are not covered.
What exactly must be posted?
For Medicare Advantage, 42 CFR 422.122(c) lists nine items from the previous calendar year, at the contract level, posted on the organization's website by March 31: the list of items and services requiring prior authorization; the percentage of standard requests approved, denied and approved after appeal; the percentage of requests where the review timeframe was extended and the request approved; the percentage of expedited requests approved and denied; and the average and median time from submission to decision for standard and for expedited requests. Drugs are excluded.
What decision timeframes apply?
Impacted payers other than exchange issuers must send prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests, and since January 1, 2026 must give a specific reason for every denial. The Prior Authorization API that lets systems submit and track requests is required from January 1, 2027.
Where can we find a payer's posting?
On the payer's own website; the rule does not create a central CMS database. Search the payer's provider or transparency pages for prior authorization metrics or data, and record the URL and the posting date, because the figures are replaced each March.
- 42 CFR 422.122, Prior authorization requirements (eCFR, current as of October 22, 2026): denial reasons, Prior Authorization API, public reporting of metrics
- CMS fact sheet: CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), January 17, 2024
- CMS, Interoperability and Prior Authorization Final Rule (CMS-0057-F) overview
- CMS, Electronic Prior Authorization overview (page updated October 21, 2026)
Checked October 25, 2026. Rules change; confirm against the source before relying on them.
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We collect every payer’s posting, compare it with your turnaround and denial yield, and hand you the register with the payers to escalate first.