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 emphasizes the need to improve health information exchange to achieve appropriate and necessary access to health records for patients (members), healthcare providers, and payers. The rule also focuses on efforts to improve prior authorization processes through policies and technology, to help ensure that patients remain at the center of their own care.
This final rule requires MassHealth to adjudicate Prior Authorization requests (excluding drugs) within 7 calendar days, or 72 hours for expedited requests. The implementation date for this is 1/1/2026.
Beginning 3/31/2026, MassHealth will post prior authorization metrics to Mass.gov. The metrics will be updated on an annual basis.
This final rule requires impacted payers to implement and maintain a Patient Access Application Programming Interface (API), a Provider Access API, a Payer-to-Payer API, and a Prior Authorization API. The expected implementation date for the APIs is 1/1/2027.
MassHealth will be issuing an All-Provider Bulletin in the near future with details. Information sessions are also being planned and further details on these sessions will be made available soon.
For questions or concerns:
LTTS providers, please contact the LTSS Provider Service Center at (844) 368-5184 or support@masshealthltss.com.
All other providers, please contract MassHealth at (800) 841-2900 or provider@masshealthquestions.com.