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LUGPA Policy Update - CMS Brings Greater Transparency to Prior Authorization

September 2026

At a Glance

CMS is requiring Medicare Advantage, Medicaid, CHIP, and certain Affordable Care Act Marketplace plans to publicly report key data on their use of prior authorization. Beginning in 2026, these plans must post the previous year’s metrics—including approval and denial rates, appeal outcomes, and response times—on their public websites.

CMS recently released updated guidance and a recommended reporting template to clarify these requirements. On August 18, the American Medical Association welcomed the clarifications after documenting incomplete or inaccessible reporting by some Medicare Advantage plans. The first public reports, covering calendar year 2025 data, are due in 2026.

For LUGPA members, this new transparency offers an important source of objective information on payer practices and can strengthen efforts to reduce prior authorization-related administrative burdens and delays in patient care.

What CMS Is Requiring

Impacted payers must publicly report:

  • The medical services and items subject to prior authorization, excluding drugs;
  • The percentage of standard requests approved and denied;
  • The percentage of requests approved after appeal;
  • Average and median response times for standard and expedited requests; and
  • The percentage of requests approved after the payer extended the review period.

CMS requires MA organizations to report at the contract level, making it possible to examine differences among individual MA plans. The information must be publicly accessible and cannot be limited to password-protected provider or member portals.

Beginning January 1, 2026, impacted MA plans and several other payers must also provide prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests.

Why It Matters to LUGPA

Prior authorization continues to create significant administrative work for independent practices and can delay access to diagnostic services, procedures, and other medically necessary care. Until now, much of the information about how individual payers use prior authorization has been difficult to compare systematically.

The new CMS reporting creates an opportunity to evaluate payer performance using standardized measures. For example, LUGPA and its members will be able to examine whether particular plans have:

  • Higher-than-average denial rates;
  • Significant numbers of approvals only after an appeal;
  • Longer response times;
  • Frequent extensions of review periods; or
  • Broad prior authorization requirements for urologic services.

CMS specifically notes that the reported information can help providers evaluate payer performance and compare plans, programs, and payers.

Bottom Line

CMS's new reporting requirement does not eliminate prior authorization, but it creates greater transparency and a new source of data on how health plans administer it. For LUGPA, that transparency could help quantify payer practices, support member concerns with objective evidence, and strengthen advocacy for reforms that reduce administrative burden and protect timely access to urologic care.

CMS Prior Authorization Metrics Reporting – Overview & Template