Prior Authorization Decision Clock Tracker: 72 Hours and 7 Days
Track every authorization request against the decision deadline that applies to it, and escalate in writing when a payer runs past 72 hours or 7 calendar days.
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Direct answer
Prior authorization decision deadline tracker: what operators need to know
Track every authorization request against the decision deadline that applies to it, and escalate in writing when a payer runs past 72 hours or 7 calendar days. Two deadlines matter: 72 hours expedited and 7 calendar days standard, for the programs the rule reaches.
Since 2026, the Medicare and Medicaid programs reached by the CMS Interoperability and Prior Authorization Final Rule have had to decide standard prior authorization requests within 7 calendar days and expedited requests within 72 hours, with extensions of up to 14 calendar days where the applicable rule allows. Those are deadlines with regulatory text behind them, and almost no provider tracks them. Payer slowness is absorbed as a fact of life rather than recorded as a missed obligation.
That is a missed opportunity, because a dated log of late decisions is one of the few pieces of leverage a mid-sized behavioral-health group actually has. It supports expedited handling requests, it supports escalation, and at contract renewal it is a number rather than a complaint. This guide shows which deadline applies to which request and gives you the tracker.
Key takeaways
The short version
- Two deadlines matter: 72 hours expedited and 7 calendar days standard, for the programs the rule reaches.
- The rule does not reach employer-sponsored plans, so for much commercial volume the deadline is contractual rather than regulatory.
- Calendar days, not business days. A Friday submission does not get the weekend back.
- Extensions are permitted up to 14 calendar days where the applicable rule allows, so record whether an extension was taken and on what stated basis.
- Expedited status can be requested where delay would seriously jeopardise the enrollee; record who certified that and when.
- A late decision is worth recording even when the answer is yes, because the pattern is the asset.
Take the template with you
Free to copy · no email required
Decision clock tracker
One row per request with plan type, deadline basis, computed due date, extension and expedited fields, escalation dates, and the outcome — enough to compute median turnaround and late-decision rate by payer.
request_ref,payer,plan_type,deadline_basis,level_of_care,request_type,submitted_date,submitted_time,channel,payer_reference,submission_proof_held,expedited_requested,expedited_certified_by,expedited_granted,standard_due_date,expedited_due_datetime,info_requested_dates,info_supplied_dates,payer_asserted_new_clock_start,extension_taken,extension_basis_stated,extension_due_date,decision_date,elapsed_calendar_days,past_deadline,escalation_sent_date,escalation_response_date,outcome,owner,notes PA-0001,[payer],Medicare Advantage,42 CFR 422.568 (7 calendar days),PHP,initial,2026-10-06,09:40,portal,[reference],yes — portal confirmation saved,no,,,2026-10-13,,2026-10-09,2026-10-09,no,no,,,,,,,,pending,[name], PA-0002,[payer],Medicaid MC,42 CFR 438.210(d) (72 hours expedited),Detox,initial,2026-10-10,16:05,fax,[reference],yes — transmission report saved,yes,"[clinician, credentials]",yes,,2026-10-13T16:05,,,no,no,,,2026-10-14,4,yes,2026-10-14,,approved,[name],decision 1 day past 72-hour deadline; escalation sent same day
Saves as prior-authorization-decision-clock-tracker.csv
Late-decision escalation note
A short factual escalation citing the applicable deadline, for use when a decision runs past the timeframe for that plan type.
1. Which deadline applies to this request
The deadline follows the plan type, and the same insurer will run several. Getting this wrong in either direction is costly: assuming a regulatory deadline that does not apply makes an escalation letter wrong, and assuming none applies leaves real leverage unused.
| Plan type | Standard | Expedited | Controlling text |
|---|---|---|---|
| Medicare Advantage | 7 calendar days | 72 hours | 42 CFR 422.568; 42 CFR 422.572 |
| Medicaid managed care | 7 calendar days | 72 hours | 42 CFR 438.210(d), rating periods from January 1, 2026 |
| State Medicaid fee-for-service | 7 calendar days | 72 hours | 42 CFR 440.230(e) |
| State CHIP fee-for-service | 7 calendar days | 72 hours | 42 CFR 457.732 and CMS guidance |
| QHP on a federally facilitated exchange | Not changed by CMS-0057-F | Not changed by CMS-0057-F | 45 CFR 156.223; CMS's template lists 72 hours urgent and 15 days standard |
| Employer-sponsored group health | Set by the plan and ERISA claims rules | Set by the plan and ERISA claims rules | 29 CFR 2560.503-1; plan documents |
2. Starting the clock defensibly
An escalation is only as good as your evidence of when the request was received. Portal timestamps, fax confirmations, and reference numbers are the record; a note saying 'submitted Tuesday' is not. Capture the proof at submission, because reconstructing it three weeks later is usually impossible.
Expect disputes about completeness. A payer that considers a request incomplete may treat the clock as starting when the missing item arrived. That is exactly why the tracker records both your submission and every subsequent request for information, with dates.
- Record submission date and time, the channel used, and the payer's reference or confirmation number.
- Keep the submission artifact: portal confirmation screen, fax transmission report, or acknowledgement message.
- Record every request for additional information with its date, what was asked for, and when you responded.
- Note whether the payer asserted a new clock start, and on what basis.
- Record whether expedited status was requested, who certified the clinical basis, and whether the payer granted it.
- Compute elapsed calendar days to decision automatically rather than by eye, so the log stays honest under load.
3. Escalating a late decision
- 01
Confirm the deadline before writing
Check the plan type, whether an extension was taken, and whether the payer asserted a later clock start. Escalating against the wrong deadline costs credibility you will want later.
- 02
Raise it in writing, citing the applicable provision
A short, factual note: request received on this date, decision due on this date, no decision as of today, citing the rule for that plan type. Ask for an immediate determination.
- 03
Ask what the delay means for the patient
Where treatment is being withheld pending a decision, say so plainly and ask for expedited handling on that basis if it is clinically supportable.
- 04
Record the response, including silence
Silence in response to a written escalation is itself a data point, and a useful one in aggregate.
- 05
Escalate the pattern, not the case
One late decision is an operational annoyance. Thirty late decisions with dates, by payer, is material for provider relations, a plan sponsor, or a state regulator.
- 06
Bring it to renewal
Median days to decision and late-decision rate by payer are contract-conversation numbers. They are far more persuasive than the general observation that a payer is slow.
4. Cross-check against what payers publish
Impacted payers already publish annual prior authorization metrics, including average and median time to decision, at the contract, plan, state, or issuer level depending on payer type. That gives you something unusual in payer relations: a published figure to compare your own experience against.
The comparison is often the most useful part of the exercise. A payer whose posted median is one day, against your own median of nine for behavioral-health requests, has either a behavioral-health delegate performing differently from the parent or an aggregate that hides your service lines. Either is a specific, answerable question rather than a grievance.
| What you compute | What the payer posts | The question it raises |
|---|---|---|
| Your median days to decision for this payer | Posted median for the contract, plan, or issuer | Why your behavioral-health experience differs from the aggregate |
| Your late-decision rate | Posted average and median times | Whether the aggregate includes the delegate handling your requests |
| Your expedited grant rate | Posted expedited approval and denial percentages | Whether expedited requests are being reclassified as standard |
| Your extension rate | Posted share approved after an extended timeframe | Whether extensions are routine rather than exceptional |
| Your denial rate by level of care | Aggregate across all items and services | Whether behavioral-health lines sit far below the aggregate |
5. Running the tracker
- One row per request, with the plan type field driving which deadline applies rather than a human remembering.
- Compute the due date at submission, not when someone wonders whether it is late.
- Give the log a daily sort by due date, and a weekly review of everything past due.
- Record outcomes on every row, including approvals, because turnaround is the measure and it includes the yeses.
- Report two numbers by payer: median days to decision and share of decisions past the applicable deadline.
- Keep twelve months of history. The value of this log is almost entirely in its pattern, and a quarter is not enough to take to a renewal.
Common questions
Answers before you build.
Do these deadlines apply to commercial employer-sponsored plans?+
No. CMS-0057-F reaches Medicare Advantage, Medicaid and CHIP fee-for-service, Medicaid and CHIP managed care, and qualified health plan issuers on the federally facilitated exchanges. For employer-sponsored coverage the timeframe comes from the plan documents and the ERISA claims procedure rules, so your escalation cites the plan rather than the rule.
Are the 7 days calendar or business days?+
Calendar days, which is why a Friday submission is more exposed than a Monday one. Compute the due date as a date rather than counting working days, and let the tracker do it.
What counts as a valid reason for the payer to extend?+
The applicable rule sets the conditions and caps the extension at 14 calendar days. Rather than arguing the standard in the abstract, record the basis the payer stated. A payer that extends routinely without a stated basis is showing you a pattern.
Is a late decision worth escalating if the answer was yes?+
Escalating the individual case, usually not. Recording it, always. Turnaround is the measure you will take to provider relations and to renewal, and excluding the approvals would understate it.
What if the payer says the clock restarted when we sent more records?+
Record the assertion, the date, and exactly what was requested and supplied. Whether a clock restarts is often contestable, and the only way to contest it is to have the original submission proof and the full sequence of information requests in one place.
Practical closeout
Use this operator checklist.
- Two deadlines matter: 72 hours expedited and 7 calendar days standard, for the programs the rule reaches.
- The rule does not reach employer-sponsored plans, so for much commercial volume the deadline is contractual rather than regulatory.
- Calendar days, not business days. A Friday submission does not get the weekend back.
- Extensions are permitted up to 14 calendar days where the applicable rule allows, so record whether an extension was taken and on what stated basis.
- Expedited status can be requested where delay would seriously jeopardise the enrollee; record who certified that and when.
- A late decision is worth recording even when the answer is yes, because the pattern is the asset.
Continue through the cluster
Verified customer case studies are added only with customer permission and supporting evidence; none is implied by these operational examples.
Codes on this topic
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Sources & methodology
Trace the operational claims.
Marsa Health Editorial reviewed the primary and research sources below on October 18, 2026. We translate them into workflow controls, distinguish proposals from final rules, and flag where plan, program, state, contract, or clinical requirements vary.
- 0142 CFR 422.568: Standard organization determination timeframes Electronic Code of Federal RegulationsSets the 7-calendar-day standard decision deadline for Medicare Advantage items and services subject to prior authorization, beginning January 1, 2026.Accessed or rechecked October 18, 2026
- 0242 CFR 422.572: Expedited organization determinations Electronic Code of Federal RegulationsKeeps the 72-hour expedited decision deadline and sets the conditions under which an enrollee or physician can demand one.Accessed or rechecked October 18, 2026
- 0342 CFR 438.210: Coverage and authorization of services Electronic Code of Federal RegulationsParagraph (d) sets 7-calendar-day standard and 72-hour expedited decision limits for rating periods beginning on or after January 1, 2026; (c) governs notice of adverse benefit determination.Accessed or rechecked October 18, 2026
- 0442 CFR 440.230: Sufficiency of amount, duration, and scope Electronic Code of Federal RegulationsParagraph (e) sets the 2026 decision timeframes for state Medicaid fee-for-service programs and the state-level public metrics duty.Accessed or rechecked October 18, 2026
- 05CMS Interoperability and Prior Authorization Final Rule CMS-0057-F Centers for Medicare & Medicaid ServicesThe fact sheet listing which payers are impacted, the four required APIs, the denial-reason duty, and the compliance dates.Accessed or rechecked October 18, 2026
- 0642 CFR 422.122: Prior authorization requirements Electronic Code of Federal RegulationsParagraph (c) requires Medicare Advantage organizations to post prior-year prior authorization metrics at the contract level by March 31, beginning in 2026.Accessed or rechecked October 18, 2026
- 07Electronic Prior Authorization Centers for Medicare & Medicaid ServicesCurrent CMS provider-readiness guidance for 2027 electronic prior authorization, EHR questions, FHIR testing, and workflow preparation.Accessed or rechecked October 18, 2026
- 08Minimum Necessary Requirement U.S. Department of Health and Human ServicesHIPAA guidance on limiting uses, disclosures, and requests for protected health information when the standard applies.Accessed or rechecked October 18, 2026
Organizational author. Editorial review covers source accuracy, search intent, workflow boundaries, and human-oversight requirements. This material is educational and does not provide clinical, legal, coding, or coverage advice.
No named clinical or legal expert reviewer is attributed to this version. Marsa Health does not invent reviewer credentials.
Read our editorial methodRevision history
What changed and when
October 18, 2026
Initial publication, source review, and operational editing.