{"id":15100,"date":"2022-02-16T14:31:47","date_gmt":"2022-02-16T14:31:47","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=15100"},"modified":"2025-10-29T08:33:51","modified_gmt":"2025-10-29T08:33:51","slug":"cms-proposed-a-rule-for-improving-prior-authorizations","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/cms-proposed-a-rule-for-improving-prior-authorizations\/","title":{"rendered":"CMS Proposed a Rule for Improving Prior Authorizations"},"content":{"rendered":"

CMS recently proposed a rule to improve prior authorization processes by reducing the burden on providers and patients. This proposed rule would place new requirements on Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs, and Qualified Health Plans (QHP) issuers on the Federally-facilitated Exchanges (FFEs) to improve the electronic exchange of health care data, and streamline processes related to prior authorization. <\/span><\/p>\n

The rule would require increased patient electronic access to their health care information and would improve the electronic exchange of health information among payers, providers, and patients. Together, these policies would play a key role in reducing overall payer and provider burden and improving patient access to health information. <\/span><\/p>\n

This rule includes five sets of proposals and five requests for information. These prior authorization policies are proposed to take effect on January 1, 2023, with the initial set of metrics proposed to be reported by March 31, 2023. In this article, we shared only one proposal named \u2018Documentation and Prior Authorization Burden Reduction through APIs\u2019<\/span><\/p>\n

Documentation and Prior Authorization Burden Reduction through APIs<\/span><\/h2>\n

Prior authorization is an administrative process used in healthcare for providers to request approval from payers to provide a medical service, prescription, or supply. The prior authorization request is made before those medical services or items are rendered. While prior authorization has its benefits, patients, providers, and payers alike have experienced burdens from it. <\/span><\/p>\n

And, it has been identified as a major source of provider burnout. Providers expend staff resources to identify prior authorization requirements and navigate the submission and approval processes, resources that could otherwise be directed to clinical care, and processes that vary across payers. Patients may unnecessarily pay out-of-pocket or abandon treatment altogether when prior authorization is delayed. <\/span><\/p>\n

In an attempt to alleviate some of the administrative burdens of prior authorization and to improve the patient experience, CMS is proposing a number of policies to help make the prior authorization process more efficient and transparent.<\/span><\/p>\n