Interoperability and Prior Authorization Final Rule Requirements

The Interoperability and Prior Authorization Final Rule changes the standard authorization decisions timeframe at 42 C.F.R. § 422.568(b)(1)(ii), 42 C.F.R. §438.210(d), 42 CFR §457.495(d)(2)(i) and from 14 calendar days after receipt of the request to 7 calendar days after receipt of the request. The Centers for Medicare & Medicaid Services (CMS) and the New York State Department of Health (NYSDOH) utilize the federal standard authorization decision timeframe for certain prior authorization and concurrent review requests described in this paragraph.

Healthfirst will make determinations and provide notice within the following timeframes as outlined below.

Medicaid Managed Care, Personal Wellness Plans (HARP), Senior Health Partners (SHP), CompleteCare (MAP), and Child Health Plus (CHPlus)

Healthfirst must make determinations and provide notice within the following timeframes:

• Standard Prior Authorization: 3 business days after all necessary information is received, but no later than 7 calendar days after receipt of the request with a possible extension of up to 14 additional days.
• Prior Authorization for Inpatient Rehab Services: After an Inpatient Hospital Admit: Determinations after an Inpatient Hospital Admission will be made 1 business day after all necessary information is received, but no later than 7 calendar days after receipt of the request with a possible extension of up to 14 additional days.
• Standard Concurrent Review: 1 business day after all necessary information is received but no later than 7 calendar days after receipt of the request, with a possible extension of up to 14 additional days.
• Expedited Prior Authorization: 72 hours after receipt of the request, with a possible extension of up to 14 additional days.

Medicare Advantage and Medicare PPO

Standard Requests for a Service or Item

Beginning January 1, 2026, Healthfirst must notify the enrollee (and the physician or provider involved, as appropriate) of its determination no later than 7 calendar days after receiving the request for the standard organization determination and may extend the timeframe by up to 14 calendar days under limited circumstances.

Questions?

If you have any questions, please contact your Network Account Manager, or call Provider Services at 1-888-801-1660, Monday to Friday, 8:30am-5:30pm.