CMS Issues Proposal to Modify the Prior Authorization Process

The Centers for Medicare and Medicaid Services (CMS) recently issued a proposed rule to modify the prior authorization process for certain payers. The proposal would require payers to:

  • Include a specific reason when denying a request.
  • Publicly report certain prior authorization metrics.
  • Make decisions within 72-hours for urgent requests.
  • Make decisions within seven days for standard, non-urgent requests, which is twice as fast as existing Medicare Advantage response timelines.
  • Enable improved data exchange.

The proposal generally applies to Medicare Advantage, Medicaid and Medicaid managed care and Children’s Health Insurance Program (CHIP) and CHIP managed care plans, as well as qualified health plans on the federally facilitated exchanges. Members are encouraged to review the proposal and submit comments to the CMS by the March 13, 2023 deadline.

Members with questions should contact Jason Jorkasky at the MHA.