On January 17, 2024, the Centers for Medicare & Medicaid Services (CMS) finalized the CMS Interoperability and Prior Authorization Final Rule, establishing new requirements for specific payers to streamline prior authorization processes.
Effective in 2026, the rule requires impacted payers to respond to expedited (i.e. urgent) prior authorization requests within 72 hours and standard (i.e., non-urgent) requests within seven days. It mandates that all payers provide a specific reason for denying a prior authorization request and mandates public reporting of prior authorization metrics. The rule also requires impacted payers to implement a prior authorization application programming interface (API) to enhance the efficiency of the electronic prior authorization process between providers and payers.
Plans that will be subject to this new rule include: Medicare Advantage, Medicaid, the Children’s Health Insurance Program (CHIP) fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans offered on the Federally-Facilitated Exchanges. Read the final rule. Read CMS’ rule factsheet.
Last Updated on January 23, 2024 by Aimed Alliance
