What the New CMS Prior-Authorization Reports Can and Cannot Tell Patients in 2026

As of March 31, 2026, some health plans and public programs must start posting new prior-authorization statistics from calendar year 2025 on their public websites. For patients and clinicians, that means a process that often felt like a black box may now be a little easier to compare and question.

The change comes from a Centers for Medicare & Medicaid Services rule aimed at improving transparency and speeding some prior-authorization decisions. The new postings will not tell you everything about a plan, and they do not cover every insurer in the country. But they can give readers a clearer picture of how often requests are denied, how often approvals happen only after appeal, and how long decisions usually take.

Why this matters now

March 31, 2026 was the first deadline for affected payers to publish prior-authorization metrics from the previous calendar year. In plain language, that means the first wave of public reports should show what happened during 2025.

Prior authorization is the process insurers and public programs use when they require approval before covering certain tests, treatments, equipment, or procedures. If you have ever been told that a scan, surgery, therapy visit, or medical device needs insurer approval first, that is prior authorization.

CMS has also linked these new reports to other 2026 process changes. Beginning January 1, 2026, most affected payers must give a more specific reason when they deny a prior-authorization request. And most of those payers must send decisions within 72 hours for expedited requests and 7 calendar days for standard requests. That timing rule does not apply the same way to federally facilitated Marketplace issuers, so readers should not assume every plan in the new public reports follows identical deadlines.

Which plans and programs are covered, and which are not

The new public-reporting rule does not apply to every health plan in the United States. It applies to the payer categories named by CMS:

Medicare Advantage organizations
State Medicaid fee-for-service programs
State CHIP fee-for-service programs
Medicaid managed care plans
CHIP managed care entities
Qualified Health Plan issuers on the federally facilitated exchanges, including plans sold through the federal Marketplace

That is an important limit. Many employer-sponsored plans, many off-exchange commercial plans, and other forms of private coverage are not part of this reporting requirement. So if you are looking at your own insurance, the first question is whether your plan is actually in one of the categories above.

What readers should expect to find on plan websites

CMS says the reports are supposed to cover medical items and services that require prior authorization, excluding drugs. In other words, these new public postings are not a window into prescription drug prior authorization.

The most useful things to look for first are:

A list of services that require prior authorization. This can help patients and referring clinicians spot likely trouble points before care is scheduled.
Approval and denial rates. The reports should show the percentage of standard and expedited requests that were approved and denied.
Approvals after appeal. This can show how often an initial denial did not stand.
Average and median response times. Both matter. The median can be especially useful because it is less distorted by a small number of very slow cases.
Whether the review timeframe was extended. Even when a request is eventually approved, an extension can still mean more waiting for care.

For patients choosing coverage or preparing for a procedure, the list of services requiring prior authorization may be the most practical place to start. For clinicians and office staff, denial rates, appeal reversals, and response-time patterns may offer a clearer sense of which plans create the most administrative friction.

How the 2026 denial-reason and timing rules could help

The public website reports are only one part of the policy change. The more immediate day-to-day effect for many patients and clinicians may be the 2026 requirement that covered payers provide a specific reason when they deny a request.

That matters because a vague denial can make it hard to know what to do next. A more specific reason may help a clinician decide whether to send more documentation, correct an error, resubmit the request, or move quickly to appeal. It may also help patients better understand why a service was delayed or refused.

The new decision-time rules matter too. For most affected payers other than federally facilitated Marketplace issuers, expedited requests generally must be answered within 72 hours and standard requests within 7 calendar days. Those deadlines do not guarantee approval, but they can reduce some of the open-ended waiting that has long frustrated patients and medical offices.

What the numbers can reveal, and what they cannot

The new reports improve transparency, but they are not a full quality scorecard for a health plan.

They can help show broad patterns, such as whether a payer requires prior authorization for many services, how often requests are denied, how often denials are reversed on appeal, and how long decisions usually take. Some patients may find that more useful than relying only on anecdotes.

But the numbers also have major limits. They are aggregated across all covered medical items and services. That means they can hide important differences between, for example, imaging requests, rehab visits, home equipment, and outpatient procedures. A plan with a moderate overall denial rate could still be much tougher in one service area than another.

The reporting level matters too. Medicare Advantage data are reported at the contract level, Medicaid and CHIP fee-for-service data at the state level, Medicaid managed care and CHIP managed care data at the plan level, and federally facilitated Marketplace data at the issuer level. That means the report you find may reflect a large contract or issuer rather than the exact experience of one local network, one hospital system, or one doctor’s office.

Appeal data need caution as well. If a sizable share of requests are approved only after appeal, that may suggest some initial denials do not hold up. But these public metrics do not show the full clinical details of each case, and they do not prove an individual denial was inappropriate.

Why transparency still matters

Recent numbers help explain why these reports matter. A KFF analysis found that Medicare Advantage insurers handled nearly 53 million prior-authorization requests in 2024, denied 4.1 million of them, and overturned most appealed denials. That does not mean every denial was wrong, but it does show the scale of the system and why public reporting could matter to patients deciding how much friction a plan may create.

Survey evidence from the American Medical Association points in the same direction. In its 2024 physician survey of 1,000 practicing physicians, 93% said prior authorization delays necessary care, and 61% said it is difficult to determine whether a medical service requires prior authorization. Because that is a physician survey, not a claims database or randomized study, it should be read as evidence about clinician experience rather than as a national count of patient outcomes.

Research in JAMA Network Open has also described patient burden in cancer care, including delays, anxiety, and administrative stress tied to prior authorization. Those studies were limited to convenience samples of patients with cancer, so they should not be treated as a full picture of every insurance market or every medical condition. Still, they help explain why greater transparency matters to real families.

Outside CMS, pressure on insurers has continued to build. The Associated Press reported in 2025 that major insurers pledged to reduce the scope of some prior-authorization requirements and expand faster responses. That pledge was separate from the CMS reporting rule, but it underscored how much scrutiny the process has drawn from patients, clinicians, and policymakers.

A practical checklist for readers

If your plan or program is covered by the rule, these are the most useful questions to ask when you find the new report:

Does the service I need appear on the prior-authorization list?
What share of requests are denied?
How often are denials later approved after appeal?
How long do standard and urgent decisions usually take?
How often are review timeframes extended?

If you are already dealing with a delay or denial, it can also help to ask your clinician’s office for the exact denial reason, keep records of dates and messages, and ask about the deadline for appeal right away.

What this means for readers: The new CMS-required postings are a useful transparency tool, not a final verdict on any one plan. They can help patients ask sharper questions, help clinicians understand payer patterns, and make some parts of prior authorization less opaque. But they will not tell you everything about one diagnosis, one doctor, or one individual case.

Sources

This article is for general informational purposes only and is not medical advice. Research findings can be early, limited, or subject to change as new evidence emerges. For personal guidance, diagnosis, or treatment, consult a licensed clinician. For current outbreak or public health guidance, follow your local health department, the CDC, or another relevant public health authority.