CMS Proposed Rule

On 6th Dec 2022, the Centers for Medicare & Medicaid Services (CMS) proposed a rule that would increase patient and provider access to health information and streamline procedures to improve prior authorization process for medical items and services. CMS proposes to improve prior authorization process by requiring certain payers to implement an electronic prior authorization process, shorten the time frames to respond to prior authorization requests, and establish policies to make the prior authorization process more efficient and transparent. The rule also proposes to require certain payers to implement standards that would enable data exchange from one payer to another payer when a patient changes payers or has concurrent coverage, which is expected to help ensure that complete patient records would be available throughout patient transitions between payers.

Prior Authorization as Administrative Burden

Prior authorization is an administrative process used in health care for providers to request approval from payers to provide items or services. The prior authorization request is made before those medical items or services are rendered. While prior authorization has a role in health care, it can ensure that covered items and services are medically necessary and covered by the payer, patients, providers, and payers alike have experienced burden from the process. Prior authorization has been identified as a major source of provider burnout and can become a health risk for patients if inefficiencies in the process cause care to be delayed. Generally providers expend their staff to identify prior authorization requirements that vary across payers. Patients may unnecessarily pay out-of-pocket or abandon treatment altogether when prior authorization is delayed.

Highlights of Proposed Rule to Improve Prior Authorization Process

The proposed rule would address challenges with the prior authorization process faced by providers and patients.

The key highlights of this proposed rule are as follows:

  • Proposals include requiring the implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization.
  • They also include requirements for certain payers to include a specific reason when denying requests, publicly report certain prior authorization metrics, and send decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests, which is twice as fast as the existing Medicare Advantage response time limit.
  • Provisions require impacted payers to include a specific reason when they deny a prior authorization request, regardless of the method used to send the prior authorization decision, to both facilitate better communication and understanding between the provider and payer and, if necessary, a successful resubmission of the prior authorization request.
  • In order to further support a streamlined prior authorization process, this proposed rule would add a new Electronic Prior Authorization measure for eligible hospitals and critical access hospitals under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category.
  • Proposed policies in this rule would also enable improved access to health data, supporting higher-quality care for patients with fewer disruptions. These policies include: expanding the current Patient Access API to include information about prior authorization decisions; allowing providers to access their patients’ data by requiring payers to build and maintain a Provider Access FHIR API, to enable data exchange from payers to in-network providers with whom the patient has a treatment relationship; and creating longitudinal patient records by requiring payers to exchange patient data using a Payer-to-Payer FHIR API when a patient moves between payers or has concurrent payers.
  • These proposed requirements would generally apply to Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) agencies, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs), promoting alignment across coverage types.
  • The proposed rule also requires impacted payers to publicly report certain prior authorization metrics by posting them directly on the payer’s website or via a publicly accessible hyperlink(s) on an annual basis.
  • Finally, the proposed rule includes five requests for information related to standards for social risk factor data, the electronic exchange of behavioral health information among behavioral health providers, improving the exchange of medical documentation between certain providers in the Medicare Fee-for-Service program, advancing the Trusted Exchange Framework and Common Agreement (TEFCA), and the role interoperability can play in improving maternal health outcomes.
  • You can review the proposed rule here, and the deadline to submit comments is March 13, 2023. CMS encourages comments from all interested members of the public and, in particular, from patients and their families, providers, clinicians, consumer advocates, health care professional associations, individuals serving and located in underserved communities, and from all other CMS stakeholders serving populations facing disparities in health and health care.
  • If finalized, these prior authorization policies would take effect January 1, 2026, with the initial set of metrics proposed to be reported by March 31, 2026.
  • This rule formally withdraws the December 2020 CMS Interoperability and Prior Authorization proposed rule (85 FR 82586), but incorporates the feedback received from public commenters.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. We shared a proposed rule to improve prior authorization process for provider education, you can check refer links for a better understanding. Email us at: or call us at: 888-357-3226 for hassle-free prior authorization services.

Reference: Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule CMS-0057-P: Fact Sheet

Published By - Medical Billers and Coders
Published Date - Jan-26-2023 Back

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