---
kind: "section"
citation: "42 C.F.R. § 422.122"
title: "42"
number: "422.122"
heading: "Prior authorization requirements."
url: "https://uscodex.org/cfr/42/422.122"
---

# §422.122. Prior authorization requirements.

- (a) **Communicating a reason for denial.** Beginning January 1, 2026, if the MA organization denies a prior authorization request (excluding request for coverage of drugs as defined in [§ 422.119(b)(1)(v)](/cfr/42/422.119.md?p=b-1-v)), in accordance with the timeframes established in §§ [422.568(b)(1)](/cfr/42/422.568.md?p=b-1) and [422.572(a)(1)](/cfr/42/422.572.md?p=a-1), the response to the provider must include a specific reason for the denial, regardless of the method used to communicate that information.
- (b) **Prior Authorization Application Programming Interface (API).** Beginning January 1, 2027, an MA organization must implement and maintain an API conformant with § [422.119(c)(2) through (4)](/cfr/42/422.119.md?p=c-2..c-4), [(d)](/cfr/42/422.119.md?p=c-d), and [(e)](/cfr/42/422.119.md?p=c-e), and the standards in 45 CFR [170.215(a)(1)](/cfr/45/170.215.md?p=a-1), [(b)(1)(i)](/cfr/45/170.215.md?p=b-1-i), and [(c)(1)](/cfr/45/170.215.md?p=b-c-1) that—
  - (1) Is populated with the MA organization's list of covered items and services (excluding drugs, as defined in [§ 422.119(b)(1)(v)](/cfr/42/422.119.md?p=b-1-v)) that require prior authorization;
  - (2) Can identify all documentation required by the MA organization for approval of any items or services that require prior authorization;
  - (3) Supports a Health Insurance Portability and Accountability Act (HIPAA)-compliant prior authorization request and response, as described in [45 CFR part 162](/cfr/45/part162.md); and
  - (4) **Communicates the following information about prior authorization requests—**
    - (i) **Whether the MA organization—**
      - (A) Approves the prior authorization request (and the date or circumstance under which the authorization ends);
      - (B) Denies the prior authorization request; or
      - (C) **Requests more information.**
    - (ii) If the MA organization denies the prior authorization request, it must include a specific reason for the denial.
  - (5) In addition to the requirements of this section, an MA organization using prior authorization polices or making prior authorization decisions must meet all other applicable requirements under this part, including [§ 422.138](/cfr/42/422.138.md) and the requirements in [subpart M](/cfr/42/subpartM.md) of this part.
- (c) **Publicly reporting prior authorization metrics.** Beginning in 2026, following each calendar year that it offers an MA plan, an MA organization must report prior authorization data, excluding data on drugs as defined in [§ 422.119(b)(1)(v)](/cfr/42/422.119.md?p=b-1-v), at the MA contract level by March 31. The MA organization must make the following data from the previous calendar year publicly accessible by posting them on its website:
  - (1) **A list of all items and services that require prior authorization.**
  - (2) The percentage of standard prior authorization requests that were approved, aggregated for all items and services.
  - (3) The percentage of standard prior authorization requests that were denied, aggregated for all items and services.
  - (4) The percentage of standard prior authorization requests that were approved after appeal, aggregated for all items and services.
  - (5) The percentage of prior authorization requests for which the timeframe for review was extended, and the request was approved, aggregated for all items and services.
  - (6) The percentage of expedited prior authorization requests that were approved, aggregated for all items and services.
  - (7) The percentage of expedited prior authorization requests that were denied, aggregated for all items and services.
  - (8) The average and median time that elapsed between the submission of a request and a determination by the MA plan, for standard prior authorizations, aggregated for all items and services.
  - (9) The average and median time that elapsed between the submission of a request and a decision by the MA plan for expedited prior authorizations, aggregated for all items and services.

## Notes

### Amendments

[89 FR 8976, Feb. 8, 2024]

### Source

Source: 63 FR 35077, June 26, 1998, unless otherwise noted.

### Authority

Authority: 42 U.S.C. 1302, 1306, 1395w-21 through 1395w-28, and 1395hh.

### Source

Source: 63 FR 18134, Apr. 14, 1998, unless otherwise noted.

### Amendments

[89 FR 8976, Feb. 8, 2024]