New CMS prior authorization rule takes effect

A new CMS rule aiming to streamline Medicare Advantage and Part D prior authorizations took effect Jan. 1.

CMS issued the final rule in April. It requires that coordinated care plan prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary, according to a CMS fact sheet. 

It also requires coordinated care plans to provide a minimum 90-day transition period when a beneficiary undergoing treatment switches to a new MA plan. During this period, the new plan cannot require prior authorization for the active course of treatment. 

To ensure prior authorization is used appropriately, CMS is requiring all MA plans to establish utilization management committees to review policies annually and ensure consistency with traditional Medicare national and local coverage decisions and guidelines. 

The rule also requires that approval of a prior authorization request for a course of treatment must be valid as long as medically reasonable and necessary "to avoid disruptions in care in accordance with applicable coverage criteria, the patient's medical history and the treating provider's recommendation."

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