Choose the most specific modifier, and make sure the operative note names the separate site, side or encounter.
PTP denials are coding denials: Medicare patients can’t be billed for them, and an Advance Beneficiary Notice doesn’t shift liability.
The modifier is left off, so the second procedure is denied as part of the first procedure’s global package.
Why it matters in orthopedics
When a Medicare Advantage, Medicaid or Exchange plan requires prior authorization for a surgery, imaging study or injection, CMS-0057-F sets how fast most of those plans must answer and what they must tell you when they say no. It does not apply to Original Medicare, where the separate WISeR Model adds prior authorization in six states. Knowing which rules apply to which payer keeps authorization follow-up focused. Our WISeR guide covers the Original Medicare side.
How it works
Requirement | Applies to | Compliance date |
|---|---|---|
Decisions within 72 hours for expedited and 7 calendar days for standard requests | MA plans, Medicaid and CHIP fee-for-service programs, Medicaid and CHIP managed care (not Exchange plans) | January 1, 2026; managed care by the rating period starting on or after that date |
A specific reason for every denied prior authorization | All impacted payers | January 1, 2026; managed care and Exchange plans by the rating period or plan year starting on or after that date |
Annual public prior authorization metrics on the payer’s website | All impacted payers | First report by March 31, 2026, covering CY 2025 |
Prior Authorization, Provider Access and Payer-to-Payer APIs, plus prior authorization data in the Patient Access API | All impacted payers | January 1, 2027; managed care and Exchange plans by the rating period or plan year starting on or after that date |
The process rules cover medical items and services and exclude drugs. Public metrics include the share of standard and expedited requests approved and denied, the share approved after appeal, average and median decision times, and a list of all items and services that require prior authorization. The Prior Authorization API lets a provider’s system check whether authorization is required, see documentation requirements and exchange requests and decisions electronically.
For clinicians, the rule added an Electronic Prior Authorization attestation measure to MIPS beginning with the CY 2027 performance period. The CY 2027 Physician Fee Schedule proposed rule would make it optional, worth 10 bonus points, for that year.
Orthopedic example
On a Monday, a practice submits a standard request to a Medicare Advantage plan for an outpatient rotator cuff repair. Under the rule, the plan must decide within 7 calendar days, by the following Monday. If it denies the request, the notice must give a specific reason, such as missing documentation of a trial of conservative care, so the practice can correct it, resubmit or appeal.
Common denial triggers
The claim reaches the plan without an approved authorization on file, often reported with CARC CO-197.
The billed code, laterality or site of service differs from what was approved.
The authorization expired before the date of service.
The request lacked the clinical criteria the plan’s policy requires, such as imaging or conservative care history.
How to prevent or fix
Log the date and time of every request and follow up when a plan passes the 72-hour or 7-day mark. Read the specific denial reason, fix the gap and resubmit or appeal. Use each plan’s published list of services that require authorization to update your scheduling rules. Ask your EHR or practice management vendor how it will connect to payers’ Prior Authorization APIs as plans implement them in 2027. Confirm edge cases with the plan or your compliance team, and see our review of common orthopedic claim denials for related denial patterns.
Frequently asked questions
Does CMS-0057-F apply to traditional Medicare?
No. The rule’s requirements do not directly apply to Medicare fee-for-service. They apply to Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities and qualified health plan issuers on the federally facilitated Exchanges. Original Medicare prior authorization comes from separate CMS programs, such as the hospital outpatient department prior authorization program and the WISeR Model in six states.
Do the 72-hour and 7-day deadlines apply to drug prior authorizations?
No. CMS-0057-F excludes drugs from its prior authorization process requirements and from the Prior Authorization API. For Medicare Advantage Part B drug requests, existing federal timeframes still apply: no later than 24 hours for expedited requests and 72 hours for standard requests. The 72-hour expedited and 7-calendar-day standard deadlines cover medical items and services, such as surgery, imaging and durable medical equipment.
When must payers have the Prior Authorization API working?
Medicare Advantage organizations and state Medicaid and CHIP fee-for-service programs must implement the Prior Authorization API, Provider Access API and Payer-to-Payer API by January 1, 2027. Medicaid and CHIP managed care plans must comply by the rating period beginning on or after that date, and Exchange plans by plan years beginning on or after that date. State programs can request extensions or exemptions in certain circumstances.
Guides that cover this term
WISeR Model: Which Orthopedic Services Need Medicare Prior Authorization?
In six states, Medicare’s WISeR Model adds prior authorization or pre-payment review for knee scopes, epidural injections and spine procedures.
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The Most Common Orthopedic Claim Denials in 2026, and How to Prevent Them
Ten orthopedic denial types, the CARCs behind them, their root causes and how to prevent them, plus when to appeal or correct and resubmit.
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Related terms
Sources
CMS Interoperability and Prior Authorization Final Rule CMS-0057-F — CMS fact sheet, January 17, 2024
Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Advancing Interoperability and Improving Prior Authorization Processes (CMS-0057-F), 89 FR 8758 — Federal Register, February 8, 2024
2024 CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) — CMS, page last modified October 8, 2026
Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule (CMS-1848-P), 91 FR 43842 — Federal Register, July 16, 2026
This entry is educational and is not legal, coding-compliance or billing advice. Payer rules change often, so confirm requirements with the payer before you bill. CPT® is a registered trademark of the American Medical Association; code descriptions here are Rette’s plain-language summaries.