Here are five things to know, according to a CMS fact sheet released April 5:
- Coordinated care plan prior authorization policies can only be used to confirm the presence of diagnoses and/or ensure it is medically necessary.
- Coordinated care plans also must provide a minimum 90-day transition period when a beneficiary undergoing treatment switches to a new MA plan.
- CMS is requiring all MA plans to establish utilization management committees to review policies annually to ensure prior authorization is used appropriately.
- 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.
- CMS also prohibits ads that do not mention a specific plan name and ads that may confuse beneficiaries.
