Lead story: CMS expands the DMEPOS prior-authorization list for April 2026
Seven additional HCPCS codes became subject to nationwide prior authorization as a condition of payment, while CMS also introduced an exemption path for qualifying suppliers.
Authorization DeskA dated view of final rules, proposals, payer changes, standards releases, and operating-model shifts.
Future standards deadlineNCPDP SCRIPT 2023011 becomes the required e-prescribing versionRegulatory data submissionFirst Medicare Part C UM annual data submission becomes dueCoverage administration changeSeven additional DMEPOS codes enter nationwide required prior authorizationProposed regulationCMS releases CMS-0062-P for drug prior authorization and interoperabilityCMS proposes extending electronic prior authorization requirements to drugs
CMS-0062-P would bring drug authorizations into a broader interoperability framework while also proposing updated standards and transaction requirements.
CMS reaches its first public prior-authorization metrics deadline
The March 31 reporting milestone creates a new, imperfect public evidence layer for examining payer authorization volume, outcomes, and decision timeframes.
Authorization, utilization, and care-access intelligence
View newsroomCMS proposes extending electronic prior authorization requirements to drugs
CMS-0062-P would bring drug authorizations into a broader interoperability framework while also proposing updated standards and transaction requirements.
CMS reaches its first public prior-authorization metrics deadline
The March 31 reporting milestone creates a new, imperfect public evidence layer for examining payer authorization volume, outcomes, and decision timeframes.
Medicare Advantage organizations face a new utilization-management data submission
CMS now requires MA organizations to submit information about internal coverage criteria used by the organization or its delegates for Part C prior authorization.
HealthEdge opens GuidingCare to multiple utilization-management AI partners
The initial Decision Intelligence Ecosystem connects Anterior, Latitude Health, and Case Health AI to GuidingCare, signaling a modular market for clinical review intelligence.
HL7 publishes coordinated 2026 updates to CRD, DTR, and PAS
The three Da Vinci implementation guides define connected but distinct stages for discovering requirements, assembling documentation, and exchanging authorization requests and responses.
R1 launches an end-to-end prior-authorization service on Phare OS
The provider-side offering combines rules, payer connectivity, automation, EHR completion, and human operations across determination, submission, and follow-up.
How the market is organized
Explore allRequirements, documentation, submission, and review
Medical-service authorization moves among benefit rules, clinical records, submission channels, payer or delegate review, determinations, reasons, status, and appeals.
Read the market record →A distinct electronic prior-authorization path
Drug authorization relies on pharmacy-benefit participants and NCPDP transaction paths that should not be silently combined with medical-service workflows.
Read the market record →Criteria, review, escalation, and provenance
Operational efficiency and clinical appropriateness are separate questions. Buyers need to see who configures policy, where licensed judgment enters, and how reasons and overrides remain reviewable.
Read the market record →FHIR, X12, portals, fax, and network reach
A standard, implementation guide, connector, and production payer connection are different evidence states. The workflow map keeps those boundaries visible.
Read the market record →Rules and standards record
Explore allOrganizations in the workflow
Explore allRule and workflow ledger
Explore allFuture standards deadlineNCPDP SCRIPT 2023011 becomes the required e-prescribing version
Pharmacy ePA stakeholders need a version-specific migration, testing, and trading-partner readiness plan distinct from medical-service FHIR implementation.
Regulatory data submissionFirst Medicare Part C UM annual data submission becomes due
Coverage-criteria provenance, delegation records, version control, and regulator-ready exports become more explicit enterprise requirements.
Coverage administration changeSeven additional DMEPOS codes enter nationwide required prior authorization
DME suppliers and patient-access teams need code-level, date-specific requirement discovery and must also track supplier exemption status.
Proposed regulationCMS releases CMS-0062-P for drug prior authorization and interoperability
Pharmacy ePA networks, payers, PBMs, EHRs, pharmacies, clearinghouses, and FHIR infrastructure providers need a scenario plan that preserves the distinction between current obligations and proposed changes.
Reporting deadlineInitial CMS-0057 prior-authorization metrics become due
Plan-level public disclosures create a new benchmarking input, but files require normalization by entity, population, period, request type, and denominator before comparison.
Delegation scope changeEviCore begins handling additional Cigna authorization categories
Provider routing logic and training materials must reflect service, plan, date, and exclusion details rather than a generic payer-to-delegate relationship.
Care Access Research
Explore allPRIOR AUTH MONITOR · 2026Prior-authorization market architectureIndependent market research
Original analysis
A role-based map of payers, delegates, workflow systems, criteria providers, networks, provider automation, pharmacy ePA, and interoperability infrastructure.
The research connects the provider market, normalized capabilities, authority records, operating domains, and source limitations rather than presenting a score or universal winner.
Read the report →Conditional comparisons