Executive summary
Auth57 reviewed Meridian Care Network's published prior-authorization policies against the verified 51-state corpus for the CMS-0057-F final rule (in force · API deadline Jan 1, 2027) and the CMS-0062-P proposed rule (drug-benefit PA · Oct 1, 2027). This report identifies 12 gaps across the six states in Meridian's book, with three classified as critical (material exposure to the 2027 deadline).
The most consequential findings concern diagnostic imaging PA turnaround (TX, OH, FL diverge from the CMS-0057-F 72-hour expedited standard) and GLP-1 step-therapy documentation (5 states missing the patient-hardship exception required under CMS-0062-P as proposed). Recommendations at the end of this report map each finding to a specific remediation path and policy owner.
Scope of review
Review covered Meridian's six Medicaid MCO state markets: TX, CA, OH, FL, NY, AZ. For each state we benchmarked the client's current PA policy against Auth57's verified corpus for (a) 14 service categories under CMS-0057-F and (b) 20 drug classes under CMS-0062-P. All findings reference the authoritative state publication; source URLs and verification dates are cited inline.
Findings — CMS-0057-F (service PA)
Gaps identified against the in-force CMS-0057-F final rule. API-mediated PA is mandated effective January 1, 2027; these findings represent readiness risks.
Severity
ID
Finding
Reference
Source
Critical
G-001
TX · medicaid_mco · diagnostic_imaging
Current policy requires 14-day standard turnaround on advanced-imaging PA. CMS-0057-F requires electronic decision within 7 calendar days for standard requests effective 2027-01-01. Gap: 7-day reduction needed, plus FHIR endpoint.
§422.122(a)(2)
Critical
G-002
OH · medicaid_mco · outpatient_surgery
Expedited-PA response time published as 96 hours. CMS-0057-F caps expedited at 72 hours. Gap: 24-hour reduction + expedited pathway must be API-mediated per §422.122(a)(1)(ii).
§422.122(a)(1)(ii)
Critical
G-003
FL · medicaid_mco · home_health
Home-health PA currently handled via fax-only intake; no published API roadmap. CMS-0057-F requires electronic PA (FHIR) by 2027-01-01 across all covered services. Gap: Full API buildout — highest time-to-deliver risk in the book.
§422.122(a)(3)
Major
G-004
CA · medicaid_mco · skilled_nursing_facility
Policy documentation does not yet state the required denial-rate reporting cadence. CMS-0057-F requires annual public reporting of PA metrics per §422.122(b). Gap: reporting mechanism + data pipeline.
§422.122(b)
Major
G-005
NY · medicaid_mco · durable_medical_equipment
DME PA criteria list is current but lacks explicit reason-for-denial taxonomy. CMS-0057-F denial responses must include a specific reason code + remediation guidance. Gap: add structured denial-reason schema.
§422.122(a)(5)
Minor
G-006
AZ · medicaid_mco · physical_therapy
PT visit-cap PA aligns with federal standard. Minor gap: policy language should cite §422.122 explicitly for downstream auditability.
§422.122(a)(4)
Findings — CMS-0062-P (drug-benefit PA, proposed)
Gaps identified against the CMS-0062-P proposed rule. Comment period active; final rule anticipated with Oct 1, 2027 deadline. Findings represent proactive positioning — clients who remediate now reduce 2027 timeline risk.
Severity
ID
Finding
Reference
Source
Major
G-007
TX · medicaid_mco · glp1_weight_loss
Current policy requires documented metformin failure before GLP-1 coverage for T2DM. CMS-0062-P proposes a patient-hardship exception pathway (allergy, contraindication, prior failure on same class). Gap: exception pathway not published.
§423.128(c)
Major
G-008
CA · medicaid_mco · specialty_biologics
Specialty-biologic PA documented but step-therapy sequence is ambiguous for biosimilar interchangeability. CMS-0062-P requires clear biosimilar-first rules where interchangeability is FDA-designated. Gap: policy clarification + provider comms.
§423.128(d)
Major
G-009
OH · medicaid_mco · oncology_oral
Oral-oncology PA turnaround aligns with federal for expedited, but standard turnaround relies on a 30-day window no longer compliant with CMS-0062-P's proposed 14-day floor for oncology classes.
§423.128(b)(2)
Major
G-010
FL · medicaid_mco · hiv_antiretrovirals
Antiretroviral PA policy does not carve out the CMS-0062-P proposed continuity-of-therapy exception for established patients. Gap could surface during audit — recommend policy update this cycle.
§423.128(e)
Minor
G-011
NY · medicaid_mco · adhd_stimulants
Stimulant PA process respects DEA scheduling but does not publish explicit quantity-limit override pathway. CMS-0062-P proposes standardized override-request language. Minor. Advisable update.
§423.128(f)
Minor
G-012
AZ · medicaid_mco · immunosuppressants
Post-transplant immunosuppressant PA aligns with federal and state standards. Minor gap: policy language should explicitly reference CMS-0062-P anticipated continuity-of-therapy protection.
§423.128(e)
Recommendations
Findings map to remediation owners and target dates. Critical items should be on the 2026-Q3 roadmap; major items by 2026-Q4.
1. Stand up a FHIR-compliant PA API (targets G-001, G-002, G-003)
Build or buy a Da Vinci PA-aligned FHIR endpoint spanning all six states. Home-health (G-003) is the tall pole — start there. Estimated engineering effort: 6–9 months with vendor integration; 12+ months greenfield.
2. Standardize turnaround SLAs across the book (targets G-001, G-002, G-009)
Publish a unified 7-day standard / 72-hour expedited policy for all six states by 2026-Q3. TX, OH, FL all currently exceed the federal floor on at least one service.
3. Publish exception-pathway language for drug PA (targets G-007, G-010, G-011)
Ahead of CMS-0062-P finalization, add explicit patient-hardship and continuity-of-therapy exception language to drug PA policies. Low engineering cost, meaningful compliance signal.
4. Implement structured denial-reason reporting (targets G-004, G-005)
Adopt the §422.122(a)(5) denial-reason taxonomy; feed into the §422.122(b) annual public report. Pairs well with the FHIR buildout.
Methodology
Corpus. All findings reference Auth57's verified prior-authorization dataset: 10,402 rules across 51 states × 6 programs, human-verified with source URLs, updated continuously via the Watch pipeline. Every citation in this report is source-linked and timestamped.
Benchmarking. Client policies were reviewed against CMS-0057-F final rule text (cms.gov) and CMS-0062-P proposed rule text (federalregister.gov). State publications cited inline with each finding.
Severity classification. Critical = gap with direct 2027 deadline exposure. Major = gap creating audit or compliance risk absent remediation. Minor = advisable policy-language update with low time sensitivity.