CHA News

CMS Proposes to Streamline Prior Authorization Requirements for MA, Medicaid Managed Care Plans

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The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule that would streamline prior authorization processes for Medicare Advantage, Medicaid managed care, and federally facilitated marketplace health plans.

Among the proposals, plans would be required to respond to urgent prior authorization requests within 72 hours, and standard prior authorization requests within seven days. The proposed rule would also require plans to automate the process for providers to determine whether a prior authorization is required, identify documentation requirements, provide specific reasons for denials, and exchange prior authorization requests and decisions from their electronic health records or practice management systems.

CMS also proposes a new measure for hospitals under the Promoting Interoperability Program. The new measure would require reporting on the number of prior authorizations for medical items and services (excluding drugs) that are requested electronically.

CHA has previously advocated for similar policies, and looks forward to reviewing the proposed rule in detail. CHA will provide members with a summary of the proposed rule in the coming weeks. Comments are due March 13.