# Prior authorization has a clock now. The research is still yours.

From 2026 a federal rule gives many insurers seven days to answer and requires a reason for every denial. The hours go into preparing the request, and that is the part an agent can do.

Tyler Gibbs. 30 September 2026. 4 minute read.

A physician orders an MRI. Before the scan can be booked, someone in the practice opens the chart, finds the notes that justify it, looks up what this insurer wants for this procedure, fills in a form, and waits. If the answer is no, they find out why, if they can, and start again.

That is prior authorization. The American Medical Association surveyed 1,000 practicing physicians in December 2025. On average, their practices completed 40 prior authorizations per physician each week. Physicians and their staff spent 13 hours a week on them. 40% of the physicians said they have staff who work only on prior authorization. 95% said the process delays care.

## A federal rule now puts a clock on the insurer.

In January 2024 the Centers for Medicare and Medicaid Services finalized a rule on prior authorization. It covers Medicare Advantage plans, Medicaid and CHIP programs and their managed care plans, and insurers on the federal exchanges. From 2026, most of those payers must answer an urgent request within 72 hours and a standard one within seven calendar days. A denial has to come with a specific reason. Each payer has to publish prior authorization figures on its website every year.

From 2027, the same payers have to offer a way for a provider’s software to ask what a procedure requires, send the request, and get the answer back electronically. CMS notes that the exact dates vary by type of payer, that exchange insurers are left out of the deadlines, and that none of this applies to drugs.

## The rule speeds up the answer. The research is still yours.

Read what the rule changes and what it leaves alone. The insurer has to answer faster and say why. Nothing in it writes the request. The hours the AMA counted are spent before the clock starts: finding the right notes in the chart, matching them to this payer’s criteria, and assembling the case.

A stated reason for every denial also changes what happens after a no. KFF counted nearly 53 million prior authorization decisions by Medicare Advantage insurers in 2024. They denied 4.1 million, in full or in part. Only 11.5% of those denials were appealed, and 80.7% of the appeals overturned the denial in full or in part. Most denials that are challenged do not stand, and most are never challenged, because an appeal is the same research done a second time.

## The research is the part a machine can do.

Gathering is work a machine does well. For one hospital system, we built an agent for it. For each request, it pulls what the request needs from the health record system, internal databases, and outside sources, reasons across them, and prepares the case. Staff review it wherever a person needs to decide. The [work page](https://www.grayhavenindustries.com/work) describes it.

The same preparation serves an appeal. When the denial names its reason, the agent can pull the notes that answer that reason and draft the response for a person to send.

## The decision is the part it cannot.

Physicians are wary of this, and they have cause. In the same AMA survey, 60% said they are concerned that AI increases denial rates, or will. Their worry is about the insurer’s side of the desk, and CMS has addressed it there. In a February 2024 memo to Medicare Advantage plans, it said an algorithm or software tool can be used to assist a plan, and that algorithms or artificial intelligence “alone cannot be used as the basis to deny admission.” Medicare Advantage regulation already requires that a denial on medical necessity be reviewed by a physician or another appropriate health care professional.

The same line belongs on the provider’s side. An agent can read the chart and build the case. A clinician decides what the patient needs, and a person at the practice sends the request under their own name.

## Start with one payer and one procedure.

A practice does not need the 2027 connections to begin. Pick the request your staff file most often, with the payer that sends it back most often. Have the agent prepare those cases next to your staff for a few weeks, and compare the two: how long each took, and how many came back approved the first time. Those are numbers your team already has a feel for, and the comparison tells you whether to widen it.

## Sources

- [CMS, “CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)” fact sheet, 17 January 2024](https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f)
- [American Medical Association, 2025 AMA prior authorization physician survey](https://www.ama-assn.org/system/files/prior-authorization-survey.pdf)
- [Biniek, Sroczynski, Freed and Neuman, “Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024,” KFF, 28 January 2026](https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/)
- [CMS, “Frequently Asked Questions related to Coverage Criteria and Utilization Management Requirements in CMS Final Rule (CMS-4201-F),” 6 February 2024](https://www.aha.org/system/files/media/file/2024/02/faqs-related-to-coverage-criteria-and-utilization-management-requirements-in-cms-final-rule-cms-4201-f.pdf)
- [42 CFR § 422.566(d), who must review organization determinations](https://www.law.cornell.edu/cfr/text/42/422.566)

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Grayhaven Industries · https://www.grayhavenindustries.com/blog/prior-authorization-clock