Data Strategy Briefing — September 15, 2025
Medicare Advantage and Medicaid payers have 15 weeks left to collect 2025 prior authorization metrics for the CMS March 30 reporting deadline and to lock in 72-hour/7-day decision turnarounds taking effect January 1, 2026.
Executive briefing: The Centers for Medicare & Medicaid Services’ Interoperability and Prior Authorization final rule (CMS-0057-F) requires impacted payers to implement new turnaround times—72 hours for expedited requests and seven calendar days for standard requests—by January 1, 2026. Payers must also begin submitting annual prior authorization metrics to CMS by March 30, 2026, covering data collected during calendar year 2025. September 2025 is the last full quarter to validate data pipelines, provider notifications, and FHIR API integrations before compliance dates hit.
Key compliance checkpoints
- Metric capture. Confirm systems track required measures—including decision counts, approvals, denials, average processing times, and top denial reasons—mapped to CMS reporting templates.
- Turnaround assurance. Stress-test workflows to guarantee urgent determinations are issued within 72 hours and standard cases within seven days, documenting exception handling.
- API readiness. Advance build-out of Prior Authorization, Patient Access, and Provider Access FHIR APIs so they can surface status data that supports both the March reporting package and 2026 interoperability checks.
Operational priorities
- Provider communications. Draft notifications outlining new decision timelines and electronic submission options to satisfy the rule’s communication requirements.
- Data quality audits. Run reconciliations between utilization management platforms and data warehouses to ensure metric accuracy before exporting 2025 annual reports.
- Governance oversight. Present quarterly dashboards to compliance committees summarizing backlog trends, API deployment milestones, and exception remediation.
Enablement moves
- Automate extraction of prior authorization data into CMS’s reporting schema to avoid manual crunches in Q1 2026.
- Instrument APIs with monitoring to track uptime, response times, and FHIR conformance for audit defense.
Sources
- CMS Interoperability and Prior Authorization final rule (CMS-0057-F)
- CMS fact sheet detailing timelines and metric requirements
Zeph Tech unifies utilization management data, enforces turnaround SLAs, and pipes FHIR metrics into CMS-compliant reports.