CMS proposes rule to improve the prior authorization process

CMS issued a proposed rule that it says will streamline the prior authorization process and estimates the efficiencies introduced in the proposal would save hospitals and physician practices more than $15 billion over a 10-year period. 

The proposed requirements would generally apply to Medicare Advantage organizations, state Medicaid and Children's Health Insurance Program agencies, Medicaid managed care plans, CHIP managed care entities, and qualified health plan insurers on the federally facilitated exchanges, according to a Dec. 6 CMS news release.

The proposed rule would: 

  • Require the implementation of a Health Level 7 Fast Healthcare Interoperability Resources standard application programming interface to support electronic prior authorization. 
  • Require certain payers to include a specific reason when denying requests, publicly report certain prior authorization metrics and send decisions within 72 hours for urgent requests and seven calendar days for standard requests. 
  • Add a new electronic prior authorization measure for eligible hospitals and critical access hospitals under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System eligible clinicians under the promoting interoperability performance category.

CMS said the proposed rule would also improve access to health data. These policies include:

  • Expanding the current patient access API to include information about prior authorization decisions.
  • Allowing providers to access their patients' data by requiring payers to build and maintain a provider access FHIR API.
  • Requiring payers to exchange patient data using a payer-to-payer FHIR API when a patient moves between payers or has concurrent payers.

Read the full news release from CMS here

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