CMS Proposes New Rule to Streamline Prior Authorization Process

Last Updated: Dec 16, 2020

Prior Auth 250x250The Centers for Medicare and Medicaid Services (CMS) released a proposed rule on Dec. 10, 2020, that aims to streamline prior authorization processes by building on standards set within the Interoperability and Patient Access rule. The proposed rule includes several facets that focus on requiring payers to build and maintain application programming interfaces (APIs) to support sharing electronic data among payers, providers, and patients, and to bring transparency to the prior authorization process.

The comment period for the proposed rule will close on Jan. 4, 2021, and the rule is proposed to take effect Jan. 31, 2023.

The proposed rule would require Medicaid, CHIP, and qualified health plans on the federally-facilitated exchanges to share patient data from payer-to-payer as patients move from one payer to another. The rule also proposes that payers maintain APIs to support data sharing from payer-to-provider in order to facilitate improved coordination of care.

The rule proposes to require payers to send prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests. Payers would also be required to provide a specific reason for a denial and publicly report data about their prior authorization process, such as the percent of prior authorization requests approved, denied, and ultimately approved after appeal, and average time between submission and determination, to improve transparency into the process.

Additional Resources

CMS Fact Sheet

PAMED members with questions on the proposed rule can contact our Knowledge Center at 800-228-7823 or KnowledgeCenter@pamedsoc.org.

 

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