New York State Medicaid 2025 PRIOR AUTHORIZATION METRICS

  • Metrics also available in Portable Document Format (PDF)

Prior to January 1, 2027, by New York State Regulation, New York State Medicaid is required to send prior authorization decisions within the following timeframes:

  • 21 days for Prior Authorization requests

Beginning January 1, 2027, the CMS Interoperability and Prior Authorization final rule requires New York State Medicaid to send prior authorization decisions within:

  • 72 hours for expedited requests (urgent)
  • Seven calendar days for standard requests (non-urgent)

2025 Prior Authorization Metrics

The following metric are based on Prior Authorization requests submitted to New York State Medicaid during 2025.

Type of Decision How many times this happened Out of total requests Percentage
Request approved 100,542 119,218 84%
Request denied 18,676 119,218 16%
Requests approved after appeal 7 29 24%
Requests denied after appeal 22 29 76%

Time between receiving a prior authorization request and sending a decision.

  Mean (Average) Time Median (Middle) Time
Prior Authorization Requests 10 days 1 day
  • Mean PA request days remains within the current NYS regulatory requirement.
  • Implementation of new procedures will bring the mean closer to the CMS Interoperability standard effective January 2027.

Future Prior Authorization Metrics

The following metrics will be available based on Prior Authorization requests received during 2027 once New York State Medicaid has implemented the CMS Interoperability and Prior Authorization final rule.

Type of Decision (Non-urgent) How many times this happened Out of total requests Percentage
Request approved after time for review was extended - - -
Request denied after time for review was extended - - -
Type of Decision (Urgent) How many times this happened Out of total requests Percentage
Request approved - - -
Request denied - - -
Request approved after time for review was extended - - -
Request denied after time for review was extended - - -
  Mean (Average) Time Median (Middle) Time
Prior Authorization Requests (Non-urgent) - days - days
Prior Authorization Requests (Urgent) - days - days