Medicare Advantage plans can no longer satisfy federal prior-authorization transparency rules by posting a wall of procedure codes with no explanation of what those codes mean. The Centers for Medicare & Medicaid Services updated its guidance in recent weeks to say plainly that a list made up only of billing codes, without corresponding plain-language descriptions, does not meet the public-reporting requirement plans have had to follow since earlier this year. The change follows a review that found some insurers burying the required information or publishing numbers that did not add up.
What The Original 2024 Rule Already Required
The underlying requirement traces back to a 2024 CMS interoperability and prior authorization rule that, starting this year, forced Medicare Advantage organizations, Medicaid managed care plans, state Medicaid and Children’s Health Insurance Program agencies, and marketplace insurers to publicly report how often they use prior authorization, how often they approve or deny requests, and how long decisions take. Plans also had to post a list of the medical items and services that require prior authorization in the first place, separated by whether a request is standard or expedited.
In practice, many plans satisfied the letter of that rule while making the information nearly impossible to use. The American Medical Association reviewed how 15 Medicare Advantage contracts were complying and found problems severe enough to prompt a direct appeal to CMS, according to a summary published by the Healthcare Financial Management Association: one plan posted an 832-page list of billing codes with no plain-English explanation, other plans buried the required data behind password-protected portals, and at least one insurer published numbers it acknowledged should not be relied upon.
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The Specific Fixes CMS Ordered
CMS responded to those findings by rewriting its Prior Authorization Metrics Reporting Overview and Template to close the loopholes plans had been using. The guidance now states directly that a required list “must identify the medical items and services in a manner that is understandable to patients and providers,” and that a list consisting solely of procedure codes, such as CPT codes, without service descriptions is not considered a publicly accessible list for purposes of the reporting requirement.
The guidance also tightens what counts as “publicly accessible” in the first place. Posting the required metrics only through a password-protected member or provider portal, or tucking them somewhere on a website that cannot be reached through ordinary navigation from the plan’s public-facing homepage, no longer satisfies the rule, according to the updated language. CMS additionally specified how turnaround times should be expressed, requiring plans to report response times of less than a day in hours rather than rounding down to “0 days,” a formatting quirk that had made some plans look faster than they actually were.
Where The Reporting Requirement Still Falls Short
Patient advocates who welcomed the update say it does not fix everything. The Medicare Rights Center noted that prior-authorization data is still reported at the contract level rather than plan by plan, which means the metrics from several different plans sold under one contract get blended together, so a prospective enrollee comparing two specific Medicare Advantage plans still cannot see which one denies more requests or takes longer to decide. The reporting also excludes prior-authorization practices tied to Part D prescription drugs, covering only medical items and services billed under Part B and other medical benefits.
The organization also pointed out that the current disclosures say nothing about which services or which groups of patients face the heaviest prior-authorization burden, leaving open questions about whether certain conditions or communities are singled out more than others. The American Medical Association has pushed CMS to go further still, asking that prior-authorization metrics be surfaced directly inside Medicare’s own plan-comparison tool at the point someone is choosing a plan, rather than requiring enrollees to hunt through each insurer’s website separately. CMS has not committed to that change, though the agency’s willingness to revise the guidance once already suggests further adjustments could follow as more plans’ disclosures get scrutinized.
Why This Matters For Anyone Choosing Or Staying In A Plan
Prior authorization remains one of the most common sources of frustration reported by Medicare Advantage enrollees, since a denied or delayed authorization can hold up a scan, a procedure or a piece of durable medical equipment a doctor has already ordered. Recent polling cited by the Medicare Rights Center found that consumers view prior authorization as one of the biggest obstacles to getting care, on par with affordability itself. Even a successful appeal of a denied request carries a real cost in the form of delayed treatment, since the multi-step appeals process built into Medicare Advantage plans can stretch on for weeks while a patient waits for a service a doctor already recommended.
Clearer, plain-language disclosures give beneficiaries and the people helping them, including adult children managing a parent’s coverage, a more realistic way to see how often a given plan says no before they commit to it for a year. That matters most during the annual window when people compare Medicare Advantage plans, since a pattern of frequent denials or long waits for a decision is exactly the kind of detail a billing-code-only disclosure was never designed to reveal.
This article was produced with AI assistance and reviewed by The Financial Wire editorial team.
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Warren Cohen is a finance writer based in Phoenix, Arizona, covering personal finance topics including credit, banking, and beginner investing. He earned his degree in business administration from Arizona State University and began his career working in consumer finance, where he gained direct experience with lending and credit systems. He now writes for personal finance websites and fintech platforms, focusing on clear, practical content that helps readers make informed financial decisions.
