On December 13, 2022, the Centers for Medicare and Medicaid Services (CMS) proposed a new rule to modernize prior authorization processes for Medicare Advantage plans, Medicaid fee-for-service programs, Medicaid plans and exchange plans. The rule would streamline prior authorization processes for medical drugs and procedures by requiring payers to:
(1) implement an electronic prior authorization process;
(2) send decisions within 72 hours for urgent requests and seven calendar days for standard, non-urgent requests;
(3) implement standards to enable data exchange from one payer to another payer when a patient changes payers or has concurrent coverage to help ensure that complete patient records are available throughout patient transitions; and
(4) provide a specific reason for a denial request and publicly report certain prior authorization metrics.
The proposed rule is available here.
Last Updated on December 21, 2022 by Aimed Alliance
