CMS Prior Authorization Change Summary: Effective 01/01/2026

Starting January 1, 2026, the Centers for Medicare & Medicaid Services (CMS) will require faster turnaround times for all prior authorization (PA) requests:

• Standard PA requests must be completed within 7 calendar days. In some cases, an extension of up to 14 calendar days may apply.
• Expedited/Urgent requests must be completed within the lesser of 72 hours or the current business-day turnaround time.

To meet these timelines, please submit all required clinical information with your initial request.

Complete clinical submissions include:

• Diagnosis
• Patient history and current condition
• Treatment plan and interventions
• Relevant diagnostic tests

Tips to avoid delays:

• Response times are faster when complete clinicals are included with the request.
• Incomplete submissions may result in denial due to insufficient documentation
• Use the secure Availity portal for quicker submission and review

Resources:

For questions, please contact your provider experience representative or reach out to the PR general mailbox  at: ncproviderrelations@wellcare.com.