CMS-0057 & Policy
CMS-0057-F
Draft — pending verification
This reference entry has not yet been verified against its authoritative source (Original definitions; regulatory facts to be verified against CMS-0057-F (89 FR 8758) and X12/HL7 documentation). Do not rely on it for production configuration until this notice is removed.
In more depth
Impacted payers are Medicare Advantage organizations, state Medicaid and CHIP FFS programs, Medicaid managed care plans and CHIP managed care entities, and QHP issuers on the FFEs. Headline operational requirements: 72-hour expedited and 7-calendar-day standard PA decisions (not applied to QHPs), specific denial reasons, annual public PA metrics (first by March 31, 2026), and the 2027 API stack. Drugs are excluded from the PA provisions.