Prior Authorization
Requirements
The Centers for Medicare & Medicaid Services (CMS) has issued new rules to standardize and improve the prior authorization process across major healthcare payers – Medicare Advantage, Medicaid managed care, CHIP, and Health Insurance Marketplace plans.
New Rules to drive efficiency & better patient care.
FHIR Standard APIs
Payers must adopt the FHIR “Prior Auth Requirements, Documentation, & Decision (PARDD) API”
- Automates components of workflows that today require manual faxing, telephoning, and data entry.
- Provides real-time visibility into status of prior authorization requests for all parties.
- This allows all stakeholders to exchange relevant prior authorization information seamlessly.
Faster turnarounds
Shorten decision timeframes
- Payers must respond to a standard prior authorization request within 7 calendar days, reduced from the previous timeframes.
- For expedited urgent requests, payers must respond within 72 hours.
- Faster decisions reduce delays in access to necessary care.
Prior Authorizaiton metrics
Increasing transparency
- Payers must report standardized metrics on their prior authorization programs, like approval/denial rates, publically on their websites.
- Metrics provide comparative information to regulators on where program adjustments may be needed.
- Payers must notify both the provider and the patient regarding decisions on prior authorization requests, along with the rationale.
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