On January 17, 2024, the Centers for Medicare and Medicaid Services (CMS) issued the Advancing Interoperability and Improving Prior Authorization Processes Final Rule (the “Final Rule”). The Final Rule emphasizes the need to improve health information exchange to achieve appropriate and necessary access to health records for patients, healthcare providers, and payers. The Final Rule also focuses on efforts to improve prior authorization (PA) processes through policies and technology, to help ensure that patients remain at the center of their own care.
The Final Rule requires MassHealth to adjudicate standard PA requests under the medical benefit within 7 calendar days and expedited PA requests under the medical benefit within 72 hours. The expected implementation date for this is January 1, 2026.
The Final Rule requires that MassHealth make certain health care information, such as claims information, available to MassHealth members through the Patient Access Application Programming Interface (API). Beginning January 1, 2026, members will be able to access their health information from January 1, 2016, with a third-party application of their choice.
On November 20, 2025, MassHealth issued the All Provider Bulletin 413 at https://www.mass.gov/lists/all-provider-bulletins and published the MassHealth’s Implementation of Interoperability and Prior Authorization Requirements web page at https://www.mass.gov/masshealths-implementation-of-interoperability-and-prior-authorization-requirements which includes more details about PA process changes that are effective January 1, 2026.
MassHealth plans to conduct a series of information sessions in December 2025, to provide an overview of the upcoming changes to the PA processes and Medicaid Management Information Systems (MMIS) Provider Online Service Center (POSC) modifications. MassHealth providers impacted by these changes are encouraged to participate in the information sessions.
For questions or concerns:
LTSS providers, please contact the LTSS Provider Service Center at (844) 368-5184 or support@masshealthltss.com.
All other providers, please contact MassHealth at (800) 841-2900 or provider@masshealthquestions.com.