CMS Unveils Rule to Streamline, Quicken Prior Authorization Decisions


On December 10, 2020, the Centers for Medicare and Medicaid Services (CMS) proposed a new rule aimed at reducing the time payers take to issue a prior authorization decision and increasing payer data sharing to ease patient transfer between payers. Among other things, it requires Medicaid, CHIP, and Qualified Health Plan payers to issue decisions on prior authorizations within 72 hours for urgent requests and seven days for non-urgent requests, and payers must include a specific reason when denying a prior authorization request. This data must be publicly reported, including average wait times from submission to determination and the percentage of prior authorization requests approved, denied, and approved after appeal. The proposed rule also requires payers to share claims and encounter data with other payers to allow efficient information flow, allowing patients to take their health information with them when changing plans. CMS is accepting comments before 5:00pm EST on January 4, 2021. Read the full proposed rule here.


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