A Specialty Practice Checklist for Faster Prior Authorization Response Timelines

On Jan. 1, 2026, CMS started requiring certain payers to respond to urgent prior authorization requests within 72 hours and standard requests within seven calendar days.

This checklist can help you evaluate whether your workflows can adhere to those timelines while reducing delays tied to incomplete submissions, fragmented communication, and dual medical/pharmacy benefit pathways.

1. Does Your Workflow Match New Payer Timelines?

☐ We can consistently identify urgent vs. standard prior authorization requests.

☐ We have a documented escalation process for delayed payer responses.

☐ We monitor authorization turnaround times by payer.

☐ Staff can quickly identify where requests are stalled.

☐ We have visibility into pending authorizations across locations or providers.

☐ Our team has standardized follow-up procedures for delayed payer responses.

2. Medical vs. Pharmacy Benefit Readiness

☐ Our team can quickly identify medical vs. pharmacy benefit pathways.

☐ We have standardized documentation requirements for both workflows.

☐ Staff understand which therapies commonly trigger dual-pathway complexity.

☐ We track payer-specific submission requirements.

☐ We can quickly identify benefit-related denials.

☐ We have consistent workflows for biologic and infusion therapy authorizations.

☐ Staff know when therapies require separate pharmacy and medical benefit coordination.

☐ We maintain payer-specific requirements for specialty medications.

3. Submission Quality Check

☐ Clinical documentation requirements are standardized before submission.

☐ Lab results and chart notes are attached consistently.

☐ Prior therapy history is included when required.

☐ Requests are reviewed for completeness before submission.

☐ Submission timestamps are tracked and documented.

☐ Denial reasons are documented and categorized.

☐ We can identify common submission errors across payers.

☐ Electronic prior authorization tools are used where available rather than fax-based submissions.

☐ Staff can quickly locate missing documentation before submission.

4. Patient Access & Revenue Impact

☐ We track delayed treatment starts tied to authorization.

☐ We measure authorization-related scheduling disruptions.

☐ We monitor referral-to-treatment conversion rates.

☐ We can identify revenue delayed by pending authorizations.

☐ We review payer turnaround trends regularly.

☐ We track biologic and infusion therapy approval delays separately from standard medications.

☐ We understand how prior authorization delays affect our specialty practice revenue cycle.

☐ We can identify patient drop-off tied to delayed approvals.

5. Denials, Appeals, and Visibility

☐ We categorize denials by payer and denial reason.

☐ Staff can quickly identify appeal requirements by payer.

☐ We track repeated denial trends for specialty therapies.

☐ We monitor approval rates across Medicare Advantage and Medicaid plans.

☐ We have a consistent process for handling incomplete or returned requests.

☐ Providers have visibility into authorization status without relying on manual updates.

The CareTria Advantage

The new CMS timelines change how quickly many payers must respond to prior authorization requests. They do not eliminate fragmented workflows, incomplete submissions, or dual-pathway complexity inside specialty practices.

Practices that score gaps across multiple sections often find the root cause is the same: authorization workflows built for lower volume and simpler benefit structures that haven’t scaled with the practice. CareTria Provider Connect is built specifically for that environment — managing medical and pharmacy benefit prior authorization within one platform so specialty practices can submit more complete requests, move faster, and spend less time chasing payer responses.

Schedule a 1:1 with our team to learn more.