Overview
On January 17, 2024, the Centers for Medicare & Medicaid Services (CMS) issued the Advancing Interoperability and Improving Prior Authorization Processes final rule. This rule requires MassHealth to implement several Application Programming Interfaces (APIs) and improve the timelines for processing prior authorizations. This rule also requires that metrics about processed prior authorizations must be made available on a public website annually, effective March 31, 2026. The final rule also allows MassHealth members to have more access to their health care information through a third-party application of their choice. MassHealth will implement the requirements of the final rule based on the timeline below.
Effective January 1, 2026
MassHealth will adjudicate standard prior authorization requests under the medical benefit within seven calendar days from the date received, provided all necessary documentation is included. Expedited prior authorization requests will be reviewed within 72 hours when the member’s clinical condition requires urgent attention and a delay in processing could negatively affect health outcomes. Please refer to your specific program guidelines for more details. These timelines apply to prior authorizations for medical items and services only. Medications have their own separate rules, and those rules stay the same. Additional details regarding these process changes may be found on the Prior Authorization Process Changes and Metrics web page.
Additionally, MassHealth will make certain health care information, such as claims information, available to MassHealth members through the Patient Access API. Members will be able to access this health care information by using a third-party application of their choice. Additional details regarding how to gain access to this health care information through a third-party application will be issued soon.
Effective March 31, 2026
MassHealth will post prior authorization metrics data to Mass.gov. The metrics will be updated on an annual basis. This includes metrics about approved, modified, and denied prior authorization requests.
Additionally, MassHealth will provide CMS with the number of members that access their health care information through a third-party application utilizing the Patient Access API, and how many members access their health care information more than once.
MassHealth will keep this page updated with important information about how we are putting this new rule into place. Providers, health plans, and members should check back regularly for the latest updates. Providers should also continue to review all messages and notices from MassHealth about this work.
| Date published: | November 20, 2025 |
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