CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Authorization Process
Centers for Medicare & Medicaid Services (CMS) has released the Interoperability and Prior Authorization Final Rule (CMS-0057-F). This long-awaited final rule intends to expedite the prior authorization process. For years, health care providers have raised concerns that this process is time-consuming and inconsistent and, in many cases, still requires practices to fax information to payers. This is an unnecessarily costly process for practices and can delay critical health care services. This final rule attempts to address many of these issues in the Medicare Advantage and commercial Medicaid managed care space.
Key provisions finalized include:
- Payers must send prior authorization decisions within 72 hours for expedited (ie, urgent) requests and seven calendar days for standard (ie, non-urgent).
- Payers must include a specific reason for denying a prior authorization request.
- Payers will be required to report prior authorization metrics publicly.
- Payers will be required to implement a Health Level 7 (HL7®) Fast Healthcare Interoperability Resources (FHIR®) Prior Authorization application programming interface (API) to help facilitate the electronic prior authorization process.
View the fact sheet here.