For as long as prior authorization has existed, practices have argued with payers about how often requests are denied and how long they take, and payers have answered with anecdotes of their own. Starting this week, some of that argument gets data. The CMS Interoperability and Prior Authorization final rule, CMS-0057-F, requires impacted payers to publish a set of prior authorization metrics for calendar year 2025 on a public website by March 31, 2026, and every year after that.
The impacted payers are Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and qualified health plan issuers on the federally facilitated exchanges. Commercial employer plans are not covered, and neither is traditional Medicare, which has its own limited prior authorization programs. Prescription drugs are excluded from the rule entirely; the metrics cover medical items and services only.
The first postings are going up now, and they are uneven. Some plans have published clear tables. Some have buried a PDF three clicks into a provider portal. We have spent the last week reading them, and this article is what we have learned about finding them and using them.
Key takeaways
- The deadline is the payer's, not yours. Your job is to find, save and date the postings for the plans your patients carry.
- Approval-after-appeal is the most useful single number. A plan that reverses most of its appealed denials is telling you the appeal is worth writing.
- The 2025 numbers predate the seven-day and 72-hour decision timeframes that took effect January 1, 2026. Next year's posting is the first real compliance test.
- Aggregate rates hide service-level variation. Use them for direction and for contract conversations, not as proof about any single request.
What the rule requires payers to publish
The metrics are aggregated, not patient level, and are reported at a level that depends on the payer type: MA organizations by contract, Medicaid and CHIP managed care by plan, state fee-for-service programs by state, and exchange issuers by issuer. For each, the payer must report for the prior calendar year:
| Metric | What it tells you | What it does not tell you |
|---|---|---|
| List of items and services requiring prior authorization | The scope of the program | Whether the list changed mid-year |
| Percentage of standard requests approved | Baseline approval rate | Approval rates by service or specialty |
| Percentage of standard requests denied | Baseline denial rate | Why they were denied |
| Percentage approved after appeal | How often the plan reverses itself | How many denials were never appealed |
| Percentage of requests where the decision timeframe was extended | How often the plan used the extension provision | The reasons for extensions |
| Percentage of expedited requests approved and denied | Urgent request handling | Whether urgent requests were reclassified as standard |
| Average and median time to decision, standard and expedited | Real turnaround | Time the practice spent gathering documents before submitting |
Where to find them
The rule says a publicly accessible website. It does not say where on the website. In practice we are finding them under provider resources, under a transparency or regulatory disclosures page, or as a footnote on the prior authorization page. Search the payer's site for "prior authorization metrics" or "CMS-0057-F". If you cannot find a posting for a plan that should have one, ask your provider relations representative and note the date you asked. If the posting is still absent in April, that is a compliance question for CMS, and there is a complaint pathway through the regional office.
Remember that MA organizations report at the contract level, and a single national insurer may have dozens of contracts. Find the contract number for the plan your patients actually carry (it is on the member ID card, in the form H1234) and look for that row. Two plans from the same insurer in the same state can sit under different contracts with different numbers.
Save what you find. Download the file, or print the page to PDF, and name it with the payer, the contract and the date you saved it. Payers can revise a posting, and if you cite a number in an appeal or a negotiation in October you will want the version you saw in March.
How to read the numbers without fooling yourself
A denial rate of 6 percent looks low. But it is a rate across everything the plan authorizes, from a generic MRI to a spinal fusion, and it hides the fact that some services are approved nearly always and some are denied half the time. A high approval-after-appeal rate is the most useful single number, because it says the plan's first decisions are often wrong when challenged. A plan that reverses 70 percent of appealed denials is telling you that the appeal is worth writing.
Turnaround times are also worth attention. As of January 1, 2026 the same rule requires these payers to decide standard requests within seven calendar days and expedited requests within 72 hours. The 2025 metrics predate that requirement, so they show how the plan behaved under the old timeframes. Next year's posting will be the first real test of compliance.
Read average and median together. A median of four days with an average of nine means most requests are decided quickly and a minority sit for weeks, and the minority is probably the expensive procedures your surgical scheduler cares about. A median close to the average means the plan is consistent, for better or worse.
Reading one posting: a worked example
Here is how we walked through a single MA contract posting with a multispecialty client last week. The figures are illustrative, rounded from the kind of posting we are seeing rather than quoted from any one plan.
| Metric (calendar year 2025) | Posted value | What we told the practice |
|---|---|---|
| Standard requests approved | 91 percent | Looks fine, but it is across every service; your imaging and injection requests are a small slice |
| Standard requests denied | 9 percent | About one in eleven; compare to your own log for this plan, which showed one in six on spine injections |
| Denials overturned on appeal | 68 percent | Appeal every denial from this plan where the reason is documentation or criteria; two thirds are being reversed |
| Timeframe extended | 7 percent | Plan used the extension on a meaningful share of requests; log every extension notice in 2026 |
| Expedited requests approved | 88 percent | Slightly lower than standard; do not mark requests expedited to speed them up unless they qualify |
| Median standard decision time | 5 days | Under the new seven-day requirement already; average was 8, so watch the tail |
The practice's own authorization log for this plan showed a denial rate on spine injections roughly double the plan's overall number, and an appeal rate of about 30 percent because staff assumed appeals rarely worked. The posting changed the second number. Appeals from this plan now go out the same week as the denial.
Three ways a practice can use this
- In appeals. A denial letter that gives a specific reason (also required since January 1, 2026) can be answered with clinical documentation, and the appeal can note that the plan reverses a large share of its denials on appeal. It is not a legal argument, but it is a signal to the reviewer that the practice has done its homework.
- In contract conversations. If a plan's denial rate is twice that of its competitors in your market and its turnaround is slower, that is a cost to your practice that belongs in the next negotiation. Put a dollar figure on the staff time: hours per request, requests per month, loaded hourly cost.
- In scheduling. If a plan's median standard turnaround was nine days in 2025, do not schedule an elective procedure for a patient on that plan six days after the request goes in. Build the payer's real turnaround into the scheduling template.
What we think about the rule
It is a good start and a limited one. Aggregate rates without service-level detail let a plan hide a 40 percent denial rate on one procedure inside a 5 percent overall number. The exclusion of drugs leaves out most of the prior authorization volume that specialty practices deal with. And commercial plans, which cover most working-age patients, are untouched. Still, this is the first time practices have had any comparable data across payers, and we would use it. The most valuable thing a practice can do with it is compare the posted numbers to its own authorization log, because the gap between the two is where your specialty sits inside the plan's average.
Questions we hear
Do we need to do anything by March 31?
No. The deadline is the payer's. Your task is to find and save the postings for the plans that matter to you, because payers can update or replace them and you may want the original.
Can we hold a payer to its published turnaround?
You can hold it to the seven-day and 72-hour requirements that took effect January 1, 2026, for MA and Medicaid managed care. The published metrics are historical. If a request has been pending past the required timeframe, call, cite the rule and the date submitted, and document the call.
Where does this fit in our denial work?
Authorization denials are one of the top three categories in most practices. Knowing which payers reverse on appeal changes how you prioritize the appeal queue. Our denial management team tracks payer reversal rates for exactly this reason, and a short call is the fastest way to compare notes on a specific plan.
What to do this week
- List the MA contracts, Medicaid managed care plans and exchange issuers that cover your patients, with the contract or plan identifier from the member ID cards.
- Find each posting, save it with the date, and note where on the site it lives.
- Pull your own 2025 authorization log for each plan and put your denial rate and appeal rate next to the plan's posted numbers.
- For any plan reversing more than half of appealed denials, change the appeal policy: every documentation or criteria denial gets appealed within the week.
- Start logging submission and decision timestamps for every 2026 request so you can hold plans to the new timeframes.
