CMS proposes prior authorization interoperability for drugs
CMS and the Office of the National Coordinator for Health Information Technology (ONC) proposed on April 14, 2026 that payers support electronic prior authorization for all drugs, with an October 1, 2027 compliance date. It is a proposal only. Nothing in it is in force until a final rule is published.
Written by Salman Saeed, CEO and Co-Founder · Reviewed by a Certified Medical Coder · 
In short: proposed rule CMS-0062-P (RIN 0938-AV44, 91 FR 19890) would extend the electronic prior authorization process from the 2024 final rule to drugs. It covers Medicare Advantage, Medicaid, CHIP and federally-facilitated exchange plans, and comments closed June 15, 2026.
What did CMS propose on April 14, 2026?
CMS and ONC published a proposed rule titled Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Interoperability Standards and Prior Authorization for Drugs. It is file code CMS-0062-P, RIN 0938-AV44, at 91 FR 19890, in the Federal Register of April 14, 2026.
The proposal builds on the Interoperability and Prior Authorization final rule, CMS-0057-F, published February 8, 2024 (89 FR 8758) and effective April 8, 2024. That rule left drugs out. Commenters on it said leaving drugs out left the biggest source of delay in place, and this proposal responds to them.
What would change for drug prior authorization?
| Proposal | Applies to | Proposed date |
|---|---|---|
| Electronic prior authorization for all drugs, through the Prior Authorization API for drugs under a medical benefit and NCPDP standards for drugs under a pharmacy benefit | MA organizations, state Medicaid and CHIP fee-for-service, Medicaid and CHIP managed care, QHP issuers on the FFEs and FF-SHOPs | October 1, 2027 |
| A specific reason when a drug prior authorization is denied | State Medicaid and CHIP programs, Medicaid managed care, CHIP managed care entities, QHP issuers on the FFEs | October 1, 2027 |
| Decisions on CHIP fee-for-service drug requests within 24 hours | State CHIP fee-for-service programs | October 1, 2027 |
| Decision notice to the provider: 7 calendar days for standard non-drug requests, 72 hours for standard drug requests, 24 hours for expedited drug requests | QHP issuers on the FFEs | October 1, 2027 |
CMS also proposes that payers report their API endpoints and usage metrics to CMS, and that HHS adopt HL7 FHIR as the HIPAA standard for referral certification and authorization transactions. Those points mainly affect payer and vendor IT teams.
Who would this affect?
Directly, it affects payers, which the rule calls impacted payers. Providers are affected through the portals and EHR connections those payers would have to offer. Practices and hospitals that submit prior authorizations for infused or injected drugs billed under the medical benefit, and for drugs on the pharmacy side, would see the change first. Original Medicare is not among the impacted payers.
What should you do now?
- Keep working prior authorizations the current way. Nothing in the proposal changes today's requirements.
- List the drugs your team requests approval for, and mark whether each is billed under the medical benefit or filled through a pharmacy benefit.
- Ask your EHR vendor whether it plans to support the Prior Authorization API for drugs.
- Record your top drug denials by CARC and remark. A specific denial reason would help an appeal, as in CO-197 denials.
- Read the current process in what prior authorization is in medical billing.
What is still open?
The comment period closed June 15, 2026. CMS has to review the comments and publish a final rule, and it can change the dates or any proposal before then. Watch the Federal Register for a final rule on CMS-0062.
The 2024 rule dates still stand. For Medicare Advantage, 7-day decisions start January 1, 2026 and the API requirement starts January 1, 2027, as set out on our prior authorization service page. See also the denial management playbook and LCDs and NCDs.
Our team tracks each payer's drug authorization steps for internal medicine and other practices. Book a call to talk through yours.
- Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Interoperability Standards and Prior Authorization for Drugs (CMS-0062-P), 91 FR 19890 · Federal Register
- Federal Register volume 91, number 71, April 14, 2026, document 2026-07205 (PDF) · GovInfo
We check every rule, code and deadline against the official source. See our editorial policy.
Common questions
Straight answers from the team that does the work.
Ask a billing lead directly. A 20-minute call, Monday to Friday, 9am to 5pm Eastern.
01What is CMS-0062-P?
CMS-0062-P is the proposed rule published April 14, 2026 at 91 FR 19890. It would extend electronic prior authorization to all drugs for Medicare Advantage, Medicaid, CHIP and federally-facilitated exchange plans, building on the 2024 final rule CMS-0057-F that covered non-drug items and services.
02When would the drug prior authorization proposals start?
CMS proposes an October 1, 2027 compliance date for the drug prior authorization proposals, including electronic prior authorization and the specific denial reason. A proposal is not binding. The date could change in a final rule, so plan around the final text and not the proposed date.
03Is the comment period for the drug prior authorization proposal still open?
No. Comments had to be received by June 15, 2026. CMS now reviews them, and a final rule has to be published before any of the proposed requirements can apply to payers. Check the Federal Register for a final rule under CMS-0062.
Talk to a billing lead.
A 20-minute call about your payers, volume and setup. Monday to Friday, 9am to 5pm Eastern.