The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule that would streamline processes related to prior authorizations (PA) for medical items and services. The proposed rule would also make information on plan PA performance – such as timeliness, as well as plan reasons for and methods of denials – public to providers and beneficiaries.

The proposed rule would apply to Medicare Advantage (MA) Plans, State Medicaid and Children's Health Insurance Program (CHIP) agencies, Medicaid Managed Care Plans, CHIP Managed Care Plans, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs). CMS estimates that efficiencies introduced through these policies would save physician practices and hospitals, alone, over $15 billion over a 10-year period.
Key proposed provisions include: 

  • Address challenges with the PA process faced by providers and patients, including requirements for certain types of plans to include a specific reason when denying requests, as well as publicly report certain prior authorization metrics. Additionally, the proposed rule would require plans to send decisions within 72 hours for expedited (i.e., urgent) PA requests and seven calendar days for standard (i.e., non-urgent) requests, which is twice as fast as the existing Medicare Advantage response time limit. CMS also suggests shorter timeframes may be more appropriate such as 48 hours for urgent PA requests and five days for non-urgent PA requests.
  • Provide improved access to health data contained in patient records to providers and beneficiaries to reduce fewer disruptions in care. These policies include expanding the current source of information about prior authorization decisions, allowing providers to access patients' data by requiring plans to build and maintain more expansive patient databases accessible to providers, as well as to enable data exchange among plans to in-network providers.

These provisions would likely offer providers and beneficiaries helpful new information to understand plan PA processes and patterns of behavior. 

AHCA/NCAL will release a more thorough summary in the coming days and work with membership to comment. The deadline to submit comments is March 13, 2023.
The CMS Fact Sheet and full text of the proposed rule are both available. Please contact Mike Cheek with questions.