Reducing Prior Authorization Response Times
Jan. 29, 2026
To ensure timely access to medical care, HealthSpring is adopting Centers for Medicare & Medicaid Services guidelines for turnaround time standards for prior authorization for our Medicare members, effective Jan. 1, 2026.
What’s changing?
We’re reducing response times to up to seven calendar days for nonurgent preservice and concurrent prior authorization and admission notification. The previous response time was up to 14 calendar days.
We may extend the response time up to an additional 14 days when a member or provider requests an extension.
If the response time is extended, we’ll send a notification letter to you and the affected member explaining the delay in prior authorization determination. The notice will include information on a member's right to file an expedited grievance if they disagree with the extension.
Additional process changes in 2026
| Topic | Through Dec. 31, 2025 | Beginning Jan. 1, 2026 |
|---|---|---|
| Peer-to-peer reviews | Following an inpatient acute denial; a peer-to-peer review could occur, and decisions could be overturned after a denial is issued. |
|
| Utilization reconsiderations | An inpatient acute denial could be overturned after submission of additional information during the admission for reconsideration. |
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| Member letters | Members do not receive any notification of determinations (acute hospitalizations). | Members and hospitals will receive notification of approval or denial. |
With these changes, please be aware of the following:
Facilities are encouraged to utilize the provider portal, Availity® Essentials, to perform clinical tasks. Our payer space is HealthSpring Medicare Advantage.
Facilities must be clear about the level of care when making a request (e.g., inpatient acute or observation). If an observation level of care is requested and approved, a subsequent order for admission to inpatient status requires that a new authorization request be submitted. The inpatient level of request will be a separate determination.
Outpatient observation notification and authorization should be submitted within the Availity Essentials payer space as an “inpatient” authorization type but an “observation” bed type.
A one-time, predecision peer-to-peer may be requested during the initial concurrent review process and prior to an authorization decision. Following the authorization decision, a change cannot be made outside of the appeals process. New or additional information − including but not limited to a change in status, new event or decompensation in clinical status for reconsideration − may only be submitted via appeal.
Please refer to the applicable appeals instructions, which will be communicated via the denial notice and are accessible within the HealthSpring Provider Manual.
Questions?
If you have questions about this change, contact your Provider Performance Enablement Representative.