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

Prior Authorization (PA) Changes

Effective January 1, 2026, MassHealth will adjudicate PA 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 PA requirements. Please refer to your specific program regulations for more information.

Standard PA Requests

MassHealth will adjudicate standard PA 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 PA submission standards. For detailed submission requirements, please refer to the applicable provider manual.

Deferred PA Requests

In instances when PA 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 PA Requests

MassHealth will review expedited PA requests within 72 hours when the member’s clinical condition requires urgent attention and a delay in processing could negatively affect health outcomes. If the request doesn’t 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, don’t qualify as reasons for an expedited PA. Expedited review is only for urgent cases where a delay could cause serious harm. It’s not for convenience, preference, or routine care.

For POSC users: updates have been made to the POSC to reflect these changes. Namely, a new PA Classification field has been added to the POSC and allows providers to submit standard PAs or requests to expedite a PA. 

Metrics Reporting

Aggregated PA metrics for all items and services (excluding drugs) from Calendar Year 2025 (CY25) are available on Calendar Year 2025 Prior Authorization Metrics.

CY26 PA metrics will be available by March 31, 2027. Calendar Year PA metrics will be updated on an annual basis. PA metrics reported on include the following:

• The percentage of standard PA requests that were approved
• The percentage of standard PA requests that were denied
• The percentage of standard PA requests that were approved after appeal
• The percentage of PA requests for which the timeframe for review was extended (due to a deferral), and the request was subsequently approved
• The percentage of expedited PA requests that were approved
• The percentage of expedited PA 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 PAs
• The average and median time that elapsed between the submission of a request and a decision by the payer for expedited PAs

Additional Resources

Questions?

If you have any questions about the changes to PA, you can contact us in the following ways.

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
Last updated:	March 30, 2026