Effective Monday, Sept. 8, 2025, Partners Health Management will adopt a more defined approach when pending a Service Authorization Request (SAR) for additional information. This is to better align with requirements from the Centers for Medicare & Medicaid Services (CMS).
On Feb. 8, 2024, CMS published the Interoperability and Prior Authorization Final Rule (CMS-0057-F). The rule is effective on Jan. 1, 2026, and establishes new timeframes for prior authorization decisions in state Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs. The CMS requirements mandate that:
- Expedited (urgent) requests must receive a decision within 72 hours
- Standard (non-urgent) requests must receive a decision within seven calendar days
What is happening?
Partners is refining our SAR pend process to better align with CMS requirements, which take effect Jan. 1, 2026.
What is changing?
Effective Sept. 8, 2025, the Partners Behavioral Health (BH) and Intellectual and Developmental Disabilities (I/DD) Utilization Management will begin:
- Issuing firm deadlines for submitting missing documentation when a SAR is pended.
- Proceeding with processing the SAR once the deadline for additional information has passed.
- Making only one outreach attempt via phone and email to communicate the missing information and deadline.
Failure to respond by the deadline may result in one of the following outcomes (as appropriate):
- Unable to Process – if the request is invalid (no appeal rights).
- Administrative Denial – if the request is incomplete (with appeal rights).
- Clinical Denial – following a medical necessity review and peer review (with appeal rights) based on the available documentation.
These changes are being made proactively to support a smooth transition to the new CMS standards for the implementation deadline on Jan. 1, 2026.
What do providers need to do?
- Submit SARs with complete and accurate supporting documentation in accordance with the:
- Partners State-Funded Benefit Plan
- Partners Tailored Plan Benefit Plan
- Partners NC Medicaid Benefit Plan
- Partners Benefit Grid (which outlines documentation requirements)
- Ensure provider contact information is accurate in all authorization requests to facilitate timely communication.
- Respond promptly to requests for additional information by the deadline provided by UM staff to avoid adverse benefit determinations.
- Review Partners Provider Communication Bulletin #148 (January 2024) for more background on requests for additional information expectations.
These proactive changes will help ensure Partners remains in compliance with CMS regulations and continues to deliver timely authorization decisions.
Who can providers contact if they have questions?
- Tailored Care Management: TailoredCareManagement@PartnersBHM.org
- Utilization Management: UMQuestions@PartnersBHM.org
- Provider Network: PAS@PartnersBHM.org