CMS Issues Proposals to Improve Prior Authorization

Proposal also seeks to increase information to patients.

New proposals to improve the prior authorization process, while giving patients information on the status of prior authorization requests have been published by the Centers for Medicare & Medicaid Services (CMS).

In a proposed rule published in the Federal Register Dec.13, CMS has outlined a number of proposals to improve the prior authorization process and increase the exchange of information between health plans.  These rules apply to Medicare Advantage (MA) organizations, state Medicaid fee-for-service (FFS) programs, state Children’s Health Insurance Program (CHIP) FFS programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the federally facilitated Exchanges (FFEs), but not to commercial health plans.

CMS does not have the legal authority to apply these rules to the commercial health plan space.

Specific proposals in the rule include the following for payers to improve the prior authorization process:

  • Requiring affected payers to automate the process for providers to determine whether a prior authorization is required, identify prior authorization information and documentation requirements, as well as facilitate the exchange of prior authorization requests and decisions from their electronic health records (EHRs) or practice management system.
  • Requiring impacted payers to include a specific reason when they deny a prior authorization request, regardless of the method used to send the prior authorization decision
  • Requiring impacted payers (not including QHP issuers on the FFEs) to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests.
  • Requiring the regulated payers to include information about patients’ prior authorization decisions in their “Patient Access API Tool” to help patients better understand their payer’s prior authorization process and its impact on their care.

These next few proposals improve interoperability among plans and providers:

  • Requiring impacted payers to build and maintain a Provider Access API tool to share patient data with in-network providers with whom the patient has a treatment relationship.
  • Require that payers would exchange patient data when a patient changes health plans with the patient’s permission.

And to monitor the impact of these requirements, merit-based incentive payment system (MIPS) eligible clinicians, eligible hospitals, and critical access hospitals (CAHs) would be required to report the number of prior authorizations for medical items and services (excluding drugs) that are requested electronically.

As for any proposed rule, CMS is accepting public comments on the proposals.  The comment period is open through March 13, 2023 (90 days from publication). The proposed rule can be found here.


Stanley Nachimson, MS

Stanley Nachimson, MS is principal of Nachimson Advisors, a health IT consulting firm dedicated to finding innovative uses for health information technology and encouraging its adoption. The firm serves a number of clients, including WEDI, EHNAC, the Cooperative Exchange, the Association of American Medical Colleges, and No World Borders. Stanley is focusing on assisting health care providers and plans with their ICD-10 implementation and is the director of the NCHICA-WEDI Timeline Initiative. He serves on the Board of Advisors for QualEDIx Corporation. Stanley served for over 30 years in the US Department of Health and Human Services in a variety of statistical, management, and health technology positions. His last ten years prior to his 2007 retirement were spent in developing HIPAA policy, regulations, and implementation planning and monitoring, beginning CMS’s work on Personal Health Records and serving as the CMS liaison with several industry organizations, including WEDI and HITSP. He brings a wealth of experience and information regarding the use of standards and technology in the health care industry.

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