August 19, 2026

2 min read

Key takeaways:

  • CMS clarified that disclosures are not publicly accessible if they require a password or cannot be easily accessed through a payer’s website.
  • AMA called for additional updates, like standardized reporting.

CMS has updated its guidance on prior authorization metrics reporting, addressing the AMA’s concerns about how health insurers were disclosing requirements and outcomes, according to the organization.

The AMA said it notified CMS about issues with reporting metrics after it conducted a review examining how 15 Medicare Advantage contracts were abiding by the transparency requirements from CMS’s 2024 Interoperability and Prior Authorization final rule.



Signing bill

CMS clarified that disclosures are not publicly accessible if they require a password or cannot be easily accessed through a payer’s website. Image: Adobe Stock

The review showed that “on the surface, many plans appeared to comply with the rule while presenting disclosures in places and formats that made them difficult or impossible to find or use,” the organization said. “Plans posted hundreds of pages of billing codes without plain-language descriptions, buried required disclosures behind physician or member portals and deep within plan websites, reported mathematically impossible statistics and turnaround times without units, and omitted entire categories of care — including behavioral health and post-acute services — from public reporting.”

“Patients should not need a portal password, a billing manual or medical training to find and understand a health plan’s prior authorization practices,” AMA President Willie Underwood III, MD, MSc, MPH, said in a press release. “Yet that is what we found when we examined how plans were implementing these transparency requirements. One plan posted an 832-page list of billing codes without a word of plain English. Others buried required information behind portals. Another published numbers that didn’t add up — and acknowledged that its data should ‘not be relied upon.’ In other words, thank you for reading this. The information may or may not be true.”

Updates to guidance

The guidance, AMA said, now clarifies that:

  • health plans must publicly identify all medical items and services needing prior authorization, “addressing the omission of entire categories of care from plan disclosures”;
  • all turnaround-time metrics need to include a time unit, and median times less than 1 day must be reported in hours rather than “0 days”;
  • disclosures are not publicly accessible “if they are available only through password-protected portals or cannot be reached through ordinary navigation from a payer’s public-facing website”; and
  • procedure codes that do not have plain-language descriptions “do not satisfy” disclosure requirements.

‘The work is not finished’

CMS “has taken an important step toward making prior authorization information more transparent and usable,” Underwood III said, “but the work is not finished.”

AMA urged CMS to continue improving its guidance on transparency by:

  • making health plans provide direct links to their prior authorization requirements and performance metrics upon enrollment and requiring states to “include the same links in Medicaid and CHIP plan-comparison and enrollment tools”;
  • defining prior authorization by how its process functions “regardless of whether a payer calls it ‘prior authorization,’ ‘precertification,’ or ‘advance notice,’ or delegating the process to a third-party utilization management vendor”; and
  • standardizing prior authorization reporting by requiring standardized templates vs. simply recommending them.

“Patients and physicians need information that is accurate, accessible, understandable and comparable across health plans. You shouldn’t have to be a rocket scientist to figure out what the insurance companies are doing,” Underwood III said. “The AMA will continue working with CMS to make sure transparency requirements actually deliver transparency.”

Sources/Disclosures

Source:


Press Release

Reference:


Disclosures:
Healio could not determine relevant financial disclosures at the time of publication.

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