CMS finalizes prior authorization process rule

January 15, 2021
Keith A. Reynolds

The final rule aims to streamline the electronic exchange of healthcare data and streamline processes to reduce administrative burden.

The Centers for Medicare & Medicaid Services (CMS) has finalized a rule aimed at improving the prior authorization process.

According to a news release, the new rule will improve the electronic exchange of healthcare data between insurers, physicians, and patients and streamlining the processes related to the prior authorization to reduce administrative burden.

“Today, we take a historic stride toward the future long promised by electronic health records but never yet realized: a more efficient, convenient, and affordable healthcare system,” CMS Administrator Seema Verma says in the release. “Thanks to this rule, millions of patients will no longer have to wrangle with prior providers or locate ancient fax machines to take possession of their own data. Many providers, too, will be freed from the burden of piecing together patients’ health histories based on incomplete, half-forgotten snippets of information supplied by the patients themselves, as well as the most onerous elements of prior authorization. This change will reverberate around the healthcare system for years and decades to come.”

The new rule requires Medicaid, CHIP, and QHP insurers to build and implement Fast Healthcare Interoperability Resources (FHIR) standard enabled application programming interfaces (API) that could allow providers to know in advance what documentation would be needed for each different health insurance payer, streamline the documentation process, and enable providers to send prior authorization requests and receive responses electronically, directly from the provider’s EHR or other practice management system, the release says.

It is expected to reduce physician prior authorization wait times by proposing a 72-hour maximum to issue decisions on urgent requests and seven calendar days for non-urgent ones. Insurers will also have to provide specific reasons for any denial as well as make public certain metrics, according to the release.

The full text of the final rule can be found here.