CMS releases proposed rule streamlining prior authorization for Medicare Advantage plans 

The Centers for Medicare & Medicaid Services tonight released a proposed rule that would require Medicare Advantage, Medicaid and federally-facilitated Marketplace health plans to streamline processes related to prior authorization. The rule would require the impacted plans to automate the process for providers to determine whether a prior authorization is required, identify documentation requirements, and exchange prior authorization requests and decisions from their electronic health records or practice management systems. The rule also would require plans to respond to urgent prior authorization requests within 72 hours and standard prior authorization requests within seven days, and both plans and providers to report on prior authorization use. 

In a statement shared with the media today, Ashley Thompson, AHA senior vice president of public policy analysis and development, said, “The AHA commends CMS for taking important steps to remove inappropriate barriers to patient care by streamlining the prior authorization process for some health insurance plans. Hospitals and health systems especially appreciate that CMS included Medicare Advantage plans in these requirements, as the AHA has urged. Prior authorization is often used in a manner that results in dangerous delays in care for patients, burdens health care providers and adds unnecessary costs to the health care system.
 
“The AHA looks forward to carefully reviewing the proposed rule, and we continue to urge the Senate to pass the Improving Seniors’ Timely Access to Care Act to codify these protections in law.”
 
AHA plans to issue a Special Bulletin on the rule for members soon.