CHA News

CMS Finalizes Rule on Prior Authorization Process

For CEOs, CFOs, finance & reimbursement staff, government relations staff, post-acute care staff

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The Centers for Medicare & Medicaid Services (CMS) – in coordination with the Office of the National Coordinator for Health Information Technology – has issued a final rule intended to streamline and reduce the burden associated with health plan prior authorization processes through Application Programming Interfaces (APIs).   

Among the final rule’s policies, CMS will require certain payers to implement APIs that would allow providers to know in advance what documentation is needed for prior authorization requests, facilitate HIPAA-compliant prior authorization requests and responses, and require plans to provide a specific reason a prior authorization request is denied.  

The final rule applies to health plans serving Medicaid, the Children’s Health Insurance Program, and the federal health insurance marketplace. Despite comments from CHA and other stakeholders, CMS did not expand the requirements to include Medicare Advantage plans. CMS will phase-in the requirements in 2023 and 2024.