CMS proposes foundational rules to standardize, automate payer prior authorization

CMS published a sweeping proposed rule on April 14 to implement prior authorization interoperability requirements from the 2021 CAA. It mandates Medicare Advantage, Medicaid managed care, CHIP, and QHP issuers to build and maintain a Patient Access API. The rule targets standardizing prior authorization processes and data exchange. This marks the start of a multi-year rebuild of the operating model. The comment period is open; track the docket (CMS-2025-XXXX) for the final rule expected late 2026, with implementation likely staggered through 2027.