CMS proposes standards for health plan prior authorization in certain federal programs

The Centers for Medicare & Medicaid Services late today issued a proposed rule that seeks to streamline prior authorization processes implemented by health plans serving the Medicaid, Children’s Health Insurance Program and federal Health Insurance Marketplace.

These plans would be required to build and implement certain application programming interfaces that could allow providers to know in advance what documentation is needed for a prior authorization request, streamline the documentation process, and enable providers to send requests and receive responses electronically, including directly from the electronic medical record or other practice management system.

Notably, Medicare Advantage plans would excluded from the rule, but the agency indicates it is considering whether to include them in future rulemaking.

For more, see the CMS news release. Comments on the rule are due Jan. 4, 2021.