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In January 2024, the Center for Medicare and Medicaid Services (CMS) issued the Interoperability and Prior Authorization Final Rule CMS-0057-F, heralding a transformative phase for U.S. healthcare payers effective January 1, 2026. This pivotal rule revises the landscape of prior authorization (PA) processes, especially for Medicare Advantage (MA), Medicaid, Children’s Health Insurance Program (CHIP), and Marketplace plans, signifying a major operational shift for healthcare payers.

The healthcare landscape is constantly evolving, and the Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F) introduces significant changes, particularly in streamlining prior authorization (PA) processes for medical services. This rule primarily impacts Medicare, Medicaid, and certain health insurance issuers under the Affordable Care Act, and commercial health plans are excluded from these mandates.