CMS' new prior authorization final rule: 5 things ASCs need to know 

CMS has issued a final rule to help streamline Medicare Advantage and Part D prior authorizations. 

Here are five things to know, according to a CMS fact sheet released April 5:

  1. Coordinated care plan prior authorization policies can only be used to confirm the presence of diagnoses and/or ensure it is medically necessary. 
  2. Coordinated care plans also must provide a minimum 90-day transition period when a beneficiary undergoing treatment switches to a new MA plan.  
  3. CMS is requiring all MA plans to establish utilization management committees to review policies annually to ensure prior authorization is used appropriately. 
  4. Approval of a prior authorization request for a course of treatment must be valid as long as medically reasonable and necessary to avoid care disruptions. 
  5. CMS also prohibits ads that do not mention a specific plan name and ads that may confuse beneficiaries. 


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