Required?
Answer 1
- The payer's list of covered items and services [1]
Home / Newsletters / The CorePulse Brief
The CorePulse Brief · Issue 1, November 2026
Prior auth API day one: what changes for your staff, and what still needs a call
Short answer: from January 1, 2027 the CMS-0057-F API returns four answers that used to be phone calls: required? documents? received? decided? The 72-hour and 7-day clocks already apply. Commercial plans, drugs and the coverage question still go to the 271, the portal or the phone.
API · Jan 1, 202772 h expedited · 7 days standardDrugs excluded · separate proposal
Edition
Issue 1 · Nov 2026
Focus
Prior auth API
Audience
Front office
Effective date
Jan 1, 2027
Metric
4 answers
Length
5 min
Jan 1, 2027
Prior Authorization API required of Medicare Advantage, Medicaid, CHIP and exchange QHP payers [1]
72h / 7 days
Expedited and standard decision clocks, generally in force since January 1, 2026, with a specific denial reason [1]
0%
Of 791 stored general-request 271s on our desk carried an authorization indicator; the API, not the 271, answers that question
4answers
Required, documents, received, decided: the calls the API replaces
What the API actually returns on January 1
The obligation sits on the payer; ask the EHR vendor about integration and module costs first [2].
Documents
Answer 2
- Identifies documentation requirements for approval [1]
Decision
Answers 3 and 4
- Received; then approved with an end date or circumstance, denied with a specific reason, or more information requested [1]
Not drugs
Excluded
- Drugs are outside the API and the clocks [1]; a separate proposed rule covers them
| Payer on your list | In scope | What staff should expect |
|---|---|---|
| Medicaid MCO, state Medicaid FFS, CHIP | Yes | API available; your system has to connect to it |
| Medicare Advantage | Yes | Same, including delegated vendors |
| Exchange QHP issuer | API yes | The 72-hour and 7-day clocks do not apply |
| Commercial employer and self-funded plans | No | Portal, fax or phone, per the contract |
| Any payer, drug authorizations | No | Pharmacy channels; a separate proposed rule |
The clocks your team can already enforce
Hours to a decision, impacted payers other than QHP issuers [1]
Since January 1, 2026, any channel. Ledger: plan, code, standard or expedited, date sent, date decided. Past the clock is an escalation in writing.
Standard request7 calendar days
168 h100%
Expedited request
72 h43%, 57% shorter
Specific denial reasonany channel
with the decisionevery denial
04896144168 h
StandardExpeditedDenial reason, both
CMS-0057-F on the front-office calendar
- 1Clocks startJan 1, 202672-hour and 7-day decisions; specific denial reasons
- 2Metrics postedMar 31, 2026First public metrics on payer websites [1]
- 3Ask every impacted payerNov 2026API go-live date and test access
- 4APIs dueJan 1, 2027Prior Authorization, Patient Access, Provider Access, Payer-to-Payer
What still needs a call
Not covered: commercial plans, drugs, and whether a benefit exists. That is still the 270/271, 0 percent authorization indicator on 791 stored responses. Routing: our API, voice and portal guide; Da Vinci CRD, DTR and PAS test kits [2].
| Question | First route | Fallback |
|---|---|---|
| Is the patient covered for this service? | 270/271 with the service type named | Voice call, reconciled to the 271 |
| Is an authorization required? | Prior Authorization API (impacted payers) or payer rule table | Portal, then phone |
| Has the request been decided? | API status; 72-hour and 7-day clocks logged | Portal, then phone |
| Why was it denied? | Specific reason returned by the API or the notice | Call for the reason, in writing |
Takeaway
Tag every payer as impacted or not, and send the impacted ones one question: what is your API go-live date, and how do we get test access?
Do this week
Export the payer list, add a columnMedicaid MCO, Medicaid FFS, CHIP, Medicare Advantage, exchange QHP, or commercial.
Record two things per impacted payerMetrics URL; API question sent, with the date.
Start the request-to-decision ledgerEvery new request from today; January begins with a baseline. Our prior authorization automation polls status on a 276/277 and portal cycle and is being wired to the API; the claim status engine has the 277 code-to-action map.
Read three notesThe CMS-0057-F deadline insight, the CMS-0062-P note on the proposed drug rule, and our eligibility system buyer's guide.
Frequently asked questions
What does the Prior Authorization API return on January 1, 2027?
Under CMS-0057-F the API must be populated with the payer's list of covered items and services, identify documentation requirements, support a request and response, and communicate whether the request is approved with the date or circumstance under which the authorization ends, denied with a specific reason, or needs more information. Drug prior authorizations are excluded.
Which payers have to run the API?
Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities and QHP issuers on the federally facilitated exchanges. Commercial employer and self-funded plans are not impacted payers.
Do the 72-hour and 7-day decision clocks apply now?
Yes, generally since January 1, 2026, for all impacted payers except QHP issuers on the federally facilitated exchanges: 72 hours for expedited requests and seven calendar days for standard requests, with a specific reason for any denial. Payers also had to post prior authorization metrics on their websites by March 31, 2026.
- CMS fact sheet, CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), January 17, 2024
- CMS, Electronic Prior Authorization overview (page updated October 21, 2026): provider steps and Da Vinci CRD, DTR and PAS test kits
- CMS, Interoperability and Prior Authorization Final Rule (CMS-0057-F) policy page
Checked October 25, 2026. Rules change; confirm against the source before relying on them. The 0 percent authorization-indicator figure is an internal measurement from our own desk in August 2026, not a client outcome.
Want your payer list tagged and the API questions sent for you?
We classify every payer under CMS-0057-F, send the go-live questions, and open the request-to-decision ledger so January starts with a baseline.