COVID-19 Information for AAOMS Members: Updates and Resources

CMS proposes new prior authorization rules

January 11, 2021

CMS released a proposed rule Dec. 10 that would require payers in Medicaid, CHIP and Qualified Health Plans (QHPs) on the Federally-facilitated Exchanges (FFEs) to improve their electronic exchange of healthcare information and streamline prior authorization processes by building and maintaining a Provider Access API for payer-to-provider sharing of claims and encounter data. These proposed new processes will allow providers to electronically access each payer’s prior authorization requirements, including the type of documentation needed by each payer and will enable providers to send prior authorization requests and receive responses electronically, directly from the provider’s EHR or practice management system.

The rule proposes that impacted payers (with the exception of QHP issuers on the FFEs):

  • Respond to prior authorization requests within 72 hours on urgent requests and seven calendar days for non-urgent requests.
  • Provide a specific reason for any denial, allowing providers some transparency in the process.
  • Publicly report data about their prior authorization process, such as the percent of prior authorization requests approved, denied and ultimately approved after appeal and average time between submission and determination.

This rule also proposes to increase patient access to their health information by requiring impacted payers to implement and maintain a FHIR-based API to exchange patient data as patients move from one payer to another. In this way, patients who would otherwise not have access to their historic health information would be able to bring their information with them when they move from one payer to another and would not lose that information simply because they changed payers.

This proposed rule does not pertain to commercial medical or dental plans, although CMS is considering whether to include similar measures for Medicare Advantage plans in future rulemaking. These prior authorization policies are proposed to take effect Jan. 1, 2023, with the initial set of metrics proposed to be reported by March 31, 2023. CMS has more information on the proposed rule.