MassHealth Interoperability Project Prior Authorization Process Changes and Metrics

Learn about MassHealth’s implementation of prior authorization process changes and metrics issued in the Advancing Interoperability and Improving Prior Authorization Processes final rule.

Background

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 process prior authorization requests under the medical benefit within seven calendar days, and expedited prior authorization requests within 72 hours, effective January 1, 2026. Metrics about processed prior authorizations must also be made available on a public website annually, effective March 31, 2026. These timelines and public reporting requirements apply to prior authorizations for medical items and services only. For drugs, existing requirements under 130 CMR 450.303(A)(1) continue to apply.

Prior Authorization Changes

Effective January 1, 2026, MassHealth will adjudicate prior authorization requests under standard and expedited timeframes. Additionally, deferral timeframes will be revised to align with new federal requirements. As applicable, these updates apply to provider types subject to prior authorization requirements. Please refer to your specific program regulations for more information.

Standard Prior Authorization Requests

MassHealth will adjudicate standard prior authorization requests within seven calendar days from the date received, provided all necessary documentation is included. This includes all relevant information about the member, clinical attachments, and any additional notes required to demonstrate compliance with the prior authorization submission standards. For detailed submission requirements, please refer to the applicable provider manual.

Deferred Prior Authorization Requests

In instances when prior authorization requests are deferred (for example, due to incomplete or missing documentation), the timeframe for review may be extended by up to 14 days from the date of the deferral. Please refer to your specific program regulations for more information. Program vendors will be updating deferral notifications to providers to reflect these revised timeframes.

Expedited Prior Authorization Requests

MassHealth will review expedited prior authorization requests within 72 hours when the member’s clinical condition requires urgent attention and a delay in processing could negatively affect health outcomes. These conditions will be evaluated on a case-by-case basis.  If the request does not meet the criteria for expedited review, it will be processed as a standard request and follow standard review processes, including the deferral process, as applicable. Please refer to your specific program guidelines for more details.

Please note that changes to the date of a scheduled procedure, or the sudden availability of clinical services, do not qualify as reasons for an expedited prior authorization. Expedited review is only for urgent cases where a delay could cause serious harm. It is not for convenience, preference, or routine care.

Metrics Reporting

Effective March 31, 2026, MassHealth will post prior authorization metrics to Mass.gov.  The metrics will be updated on an annual basis. The following aggregated prior authorization metrics for all other items and services will be available.

• A list of all items and services that require prior authorization
• The percentage of standard prior authorization requests that were approved
• The percentage of standard prior authorization requests that were denied
• The percentage of standard prior authorization requests that were approved after appeal
• The percentage of prior authorization requests for which the timeframe for review was extended (due to a deferral), and the request was subsequently approved
• The percentage of expedited prior authorization requests that were approved
• The percentage of expedited prior authorization requests that were denied
• The average and median time that elapsed between the submission of a request and a determination by the payer for standard prior authorizations
• The average and median time that elapsed between the submission of a request and a decision by the payer  for expedited prior authorizations

Additional Resources

Questions?

If you have any questions regarding the prior authorization changes, please contact:

Long-Term Services and Supports

Phone: [phone] (toll free)
Email: [e-mail]
Portal: MassHealthLTSS.com

Mail: MassHealth LTSS
PO Box 159108
Boston, MA 02215

Fax: [phone]

All Other Provider Types

Phone: [phone], TDD/TTY: 711

Email: [e-mail]

Date published:	November 20, 2025