The major changes payers face from CMS' proposed prior authorization reform

CMS issued a proposed rule Dec. 6 that it says will streamline the prior authorization process. Here are four major changes the rule would bring that would affect payers, according to a Feb. 21 report from the Kaiser Family Foundation:

1. Require payers to use the Fast Healthcare Interoperability Resources Prior Authorization Requirements, Documentation, and Decision API. This would be used to request and obtain information from plans and providers to automate the prior authorization process.  

2. Require payers to send providers information on whether a prior authorization request was approved, denied or whether more information is needed. Payers would have to include the specific reason for a denial. 

3. Require shorter timeframes for payers to make prior authorization decisions and provide notice to beneficiaries. The timeframes for standard prior authorization notices for Medicare Advantage and Medicaid managed care plans would decrease from 14 calendar days to seven. There would not be changes to timeframes from qualified health plans on the federal exchange (15 days). 

4. Require payers to annually disclose on their website a list of all services requiring prior authorization and specific aggregated metrics. These metrics would include the percentage of prior authorizations that were approved and denied, the percentage of prior authorization requests approved after appeal and the average time for a prior authorization determination. The proposed rule does not require a specific format for the disclosure.

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