CMS approves rule forcing insurers to ease prior authorization

CMS on Friday approved its plan to streamline prior authorization and improve patient and provider access to medical records.

The final rule requires payers—including Medicaid, the Children’s Health Insurance Program and exchange plans—to build application program interfaces to support data exchange and prior authorization. CMS said the changes would allow providers to know in advance what documentation each payer would require, streamline documentation processes and make it easier for providers to send and receive prior authorization information requests and responses electronically.

“The requirements of this rule specify that each of these payers will build an API-enabled documentation requirements look-up service and make these public so providers can access documentation and prior authorization requirements from their EHR platforms. Once a provider knows what is required for each prior authorization, the next step is submitting it electronically,” the agency said in a statement.

Under the rule, Medicaid and CHIP fee-for-service and managed-care plans will have up to 72 hours to make prior authorization decisions on urgent requests and seven calendar days for non-urgent requests. All covered payers must provide a specific reason for any denial.

The changes will phase in from 2023 through 2024.

Healthcare groups criticized CMS for giving them just a few weeks to review and comment on the proposed rule and excluding Medicare Advantage plans from the requirements.

Blair Childs, senior vice president of group purchasing organization Premier Inc., urged Congress to reintroduce and pass the Improving Seniors’ Timely Access to Care Act of 2019 in a statement. The legislation would rein in the prior authorization practices of Medicare Advantage plans.


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