Prior Authorization Metrics for Medical Items and Services (Excluding Drugs)

To comply with the Interoperability and Prior Authorization final rule from the Centers for Medicare & Medicaid Servies (CMS), HMSA is required to report aggregated prior authorization metrics on its website every year. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year.

Publicly reporting these metrics promotes transparency and accountability, helps patients understand prior authorization processes, and enables providers to evaluate payer performance. In addition, metrics can be used to compare plans, programs, and payers.

View the Annual Report [PDF].

View the list of all medical items and services that require prior authorization (excluding drugs).

If you have questions, call us.

Before Jan. 1, 2026, impacted payers are required to send prior authorization decisions within these time frames:

• For Medicare Advantage plans and applicable integrated plans, 72 hours for expedited requests (urgent) and 14 days for standard requests (non-urgent).
• For QUEST (Medicaid) plans, 72 hours for expedited requests (urgent) and 14 days for standard requests (non-urgent).
• For qualified health plan issuers on the federally facilitated exchanges, 72 hours for expedited requests (urgent) and 15 days for standard requests (non-urgent).

Beginning Jan. 1, 2026, the CMS Interoperability and Prior Authorization final rule requires HMSA Medicare Advantage and QUEST (Medicaid) plans to send prior authorization decisions within:

• Seventy-two hours for expedited requests (urgent).
• Seven days for standard requests (non-urgent).

There are no changes to the prior authorization decision notification time frames for qualified health plan issuers on the federally facilitated exchanges.