Prior Authorization Compliance Report
Sample Health Plan · Medicaid MCO book of business
Executive summary
Auth57 reviewed Sample Health Plan's published prior-authorization policies against the verified 51-state corpus for the CMS-0057-F final rule (in force · API deadline Jan 1, 2027) and the CMS-0062-P proposed rule (drug-benefit PA · Oct 1, 2027). This report identifies 12 gaps across the four states in the book, with 3 classified as critical (material exposure to the 2027 deadline).
The most consequential findings concern diagnostic-imaging PA turnaround (TX, OH, FL diverge from the CMS-0057-F 7-day standard) and GLP-1 step-therapy documentation (multiple states missing the patient-hardship exception required under CMS-0062-P as proposed). Each finding maps to a specific remediation path and policy owner.
Scope of review
Review covered Sample Health Plan's four Medicaid MCO state markets: TX, CA, OH, FL, with NY and AZ included as advisory comparisons. For each state we benchmarked the client's current PA policy against Auth57's verified corpus for (a) 14 service categories under CMS-0057-F and (b) 20 drug classes under CMS-0062-P. All findings reference the authoritative state publication; source URLs and verification dates are cited inline with each finding.
Findings — 12 gaps
Grouped by severity. Critical and high items should be on the 2026-Q3 roadmap.
Standard PA turnaround exceeds 7 days for non-urgent imaging
CriticalCurrent policy permits a 14-day standard turnaround on advanced-imaging PA. CMS-0057-F mandates an electronic decision within 7 calendar days for standard requests effective 2027-01-01.
Expedited PA response time exceeds the 72-hour federal cap
CriticalExpedited PA published as 96 hours. CMS-0057-F caps expedited at 72 hours and requires the pathway to be API-mediated.
Home-health PA still fax-only — no FHIR API roadmap published
CriticalHome-health prior authorization is currently handled via fax-only intake. CMS-0057-F requires electronic PA across all covered services by 2027-01-01. This is the tallest pole in the book.
Denial-reason field is unstructured free text
HighDenial notices cite "clinical criteria not met" without the specific criterion. CMS-0057-F § 422.122(a)(5) requires a structured, patient-facing reason code on every denial.
Annual public PA-metrics report not yet defined
HighPolicy documentation does not state the required denial-rate reporting cadence. CMS-0057-F § 422.122(b) requires annual public reporting of approval rates, denial rates, and average turnaround time.
DME PA criteria lacks a structured denial taxonomy
HighDME criteria list is current but lacks an explicit reason-for-denial taxonomy. CMS-0057-F denial responses must include a specific reason code plus remediation guidance for the requesting provider.
GLP-1 step-therapy missing patient-hardship exception pathway
HighCurrent policy requires documented metformin failure before GLP-1 coverage for T2DM. CMS-0062-P proposes a patient-hardship exception (allergy, contraindication, prior failure on same class) that the policy does not yet codify.
Specialty-biologic step therapy ambiguous on biosimilar interchangeability
HighSpecialty-biologic PA is documented but step-therapy sequence is ambiguous for FDA-designated interchangeable biosimilars. CMS-0062-P requires clear biosimilar-first rules where interchangeability is established.
Oral-oncology standard turnaround is 30 days — proposed floor is 14
HighOral-oncology PA turnaround aligns with federal for expedited, but standard turnaround relies on a 30-day window no longer compliant with CMS-0062-P's proposed 14-day floor for oncology classes.
HIV antiretroviral PA missing continuity-of-therapy carve-out
MediumAntiretroviral PA policy does not carve out the CMS-0062-P proposed continuity-of-therapy exception for established patients. Risk surfaces in audit; advisable update this policy cycle.
ADHD stimulant policy lacks published quantity-limit override pathway
MediumStimulant PA process respects DEA scheduling but does not publish an explicit quantity-limit override pathway. CMS-0062-P proposes standardized override-request language.
PT visit-cap policy should cite §422.122 explicitly
LowPT visit-cap PA aligns with the federal standard. Minor language update: cite § 422.122 explicitly for downstream auditability.
Methodology
Corpus.All findings reference Auth57's verified prior-authorization dataset: 10,400+ rules across 51 states × 6 programs, human-verified with source URLs, updated continuously via the Watch pipeline. Every citation in this report is source-linked and timestamped.
Benchmarking. Client policies were reviewed against CMS-0057-F final rule text and CMS-0062-P proposed rule text. State publications cited inline with each finding.
Severity classification. Critical = direct 2027 deadline exposure. High = audit or compliance risk absent remediation. Medium = advisable update with modest time sensitivity. Low = policy-language tightening, low urgency.