Payers are now required to publicly report prior authorization metrics for the first time under a rule finalized by Centers for Medicare & Medicaid Services in 2024. (CMS-0057-F)

The first reports, covering 2025 data, are due by March 31 and must be published annually on payer websites.

• Required metrics include approval rates, denial rates, decision turnaround times, and appeal outcomes for medical services, excluding drugs.
• Reporting applies across Medicare Advantage, Medicaid and CHIP programs, and ACA exchange plans, with data aggregated at the contract, state, or plan level depending on the program.

The rule also shortens decision timelines, requiring standard determinations within seven days and urgent requests within 72 hours for most government programs. Payers must provide specific reasons for denials and communicate them across multiple channels.

The reporting mandate follows sustained provider concerns about administrative burden, with physicians averaging 39 prior authorizations per week and 13 hours spent on related tasks.

In Medicare Advantage alone, 7.7% of prior authorization requests were denied in 2024, with more than 80% of appeals later overturned.

Future phases of the rule will introduce API requirements beginning in 2027 to enable electronic prior authorization workflows and data exchange. Separately, industry commitments aim to move most electronic prior authorization approvals to real-time processing.

Source: Becker’s Hospital Review