CMS proposes prior authorization updates: 5 things to know

CMS is proposing to streamline and improve prior authorizations with new and added rules, according to a Feb. 21 Kaiser Family Foundation report. 

Five notes:

1. The proposal includes new requirements for the prior authorization process and adding new timeframes for decision-making that apply for Medicare Advantage plans, Medicaid managed care plans, Medicaid fee-for-service plans, CHIP managed care and FFS arrangements and qualified health plans on the federally facilitated health insurance marketplace. The majority of the new rules wouldn't go into effect until 2026.

2. Under the proposal, affected payers would have to use a specific API, give providers relevant information about prior authorization statuses and publicly report specific metrics yearly. Metrics would include the percent of prior authorizations approved and denied and the average turnaround time for a determination. 

3. The proposal adds onto past rulemaking including the May 2020 final rule on interoperability. CMS' proposal would include added requirements to include information about prior authorizations and making historic decisions available. 

4. CMS is also proposing that payers use a specific payer-to-payer data exchange standard. Payers would also have to opt in to having their data shared between payers. 

5. CMS' proposal includes five separate requests for information that ask for feedback on data information exchange. They include developing standards for exchanging data on social risk factors, use of APIs for behavioral health services, electronic information exchange in traditional Medicare, improving prior authorization in maternal health and methods to increase adoption of the Trusted Exchange Framework.

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