Find answers to frequently asked questions about the new prior authorization rules, their requirements, and deadlines.
Patients will experience a more efficient digital prior authorization process. There will be faster decisions through automation, increased transparency from published metrics, and better notifications directly to patients. Patients can also access their own prior authorization information electronically through apps connected to payer APIs.
The requirements apply to Medicare Advantage, Managed Medicaid, CHIP, and Health Insurance Marketplace plans. They do not apply to employer plans or traditional Medicare. However, health plans are increasingly adopting digital processes voluntarily.
CMS proposes shortening the decision timeframes for prior authorizations within 72 hours for urgent requests and seven calendar days for non-urgent requests. However CMIS is also seeking comment on alternative time frames with shorter turnaround times.
The focus is on improving process efficiency, transparency and communication - not changing clinical approval criteria. Approval rates may improve if automation reduces incorrect denials due to insufficient information. But medical necessity criteria remain unchanged.
The requirements were published as an open proposed rule on the CMS website (Link).
If you still have questions or need further clarification, feel free to reach out to us. Our team is ready to assist you.
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