The Centers for Medicare & Medicaid Services (CMS) requires reporting of data related to program operations, expenditures, and outcomes. These requirements include regular submission of financial reports, eligibility and enrollment data, claims and utilization information, and performance metrics tied to federal standards and initiatives. Through these reports, CMS monitors compliance with federal regulations, assesses program integrity, evaluates quality of care, and ensures appropriate use of federal funds, while also supporting transparency and accountability across the Medicaid program.
Prior Authorization Process Changes and Metrics
The Centers for Medicare & Medicaid Services (CMS) requires reporting of data related to program operations, expenditures, and outcomes. These requirements include regular submission of financial reports, eligibility and enrollment data, claims and utilization information, and performance metrics tied to federal standards and initiatives. Through these reports, CMS monitors compliance with federal regulations, assesses program integrity, evaluates quality of care, and ensures appropriate use of federal funds, while also supporting transparency and accountability across the Medicaid program.
The Centers for Medicare & Medicaid Services (CMS) issued the Advancing Interoperability and Improving Prior Authorization Processes Final Rule (CMS-0057-F). This Final Rule requires Alabama Medicaid to process prior authorization (PA) requests under the medical benefit within seven calendar days, and expedited PA requests within 72 hours, effective January 1, 2026. Metrics about processed PAs must also be made available on a public website annually, effective March 31, 2026. These timelines and public reporting requirements apply to PAs for medical items and services only, excluding Pharmacy PAs. To learn more, visit Prior Authorization Changes and Metrics.