Effective January 1, 2026, the required turnaround time for routine Medicare and Medicaid prior authorization requests for medical services will drop from 14 to 7 calendar days. This change is directed by the Centers for Medicare & Medicaid Services (CMS) Advancing Interoperability and Prior Authorization Final Rule.
If a prior authorization request lacks complete clinical information for medical necessity review, the ordering provider will receive outreach attempts (2) by phone and one written notice before it is denied.
Important: As soon as EviCore has enough clinical information to make a determination, we’ll issue a decision, even if the seven-day period hasn’t fully elapsed. To help avoid denials, please submit complete all relevant clinical documentation with your initial request. For EviCore clinical guidelines click here.
Who this applies to:
- Medicare and Medicaid member prior authorization requests for medical services
- Note that certain states may have even shorter allowable review times based on local regulations
What’s staying the same:
The turnaround time for urgent prior authorization requests for medical services will continue to be 72 hours from receipt of complete clinical information.
As always, providers have the option of having a Peer-to-Peer discussion with one of our Medical Directors at any point during the case lifecycle.
Keep in mind:
- EviCore’s team will always try to turnaround routine prior authorizations as fast as possible. If the provided clinical information is adequate, we can finalize the determination without waiting the full seven-day period.
- A case will only be placed on hold if additional clinical information is needed to render a decision.
EviCore’s average turnaround times are already shorter than the requirements specified by the rule. We have worked for many years to create more effective, collaborative, and transparent prior authorization processes through data, technology, and innovative approaches.
Got questions? Our Regional Provider Engagement Managers are here to help! Find yours here. For full regulatory details, see CMS-0057-F, Advancing Interoperability and Prior Authorization Final Rule (89 FR 8758).