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Prior authorization process moves closer to automation


CAQH CORE, a healthcare industry-led operating standards group, has announced new rules that move the healthcare industry closer to fully automating the prior authorization process.

CAQH CORE, a healthcare industry-led operating standards group, has announced new rules that move the healthcare industry closer to fully automating the prior authorization process.

“Not only do the operating rules represent a foundational step forward in improving the prior authorization process, they also signal broad industry commitment to adopting tangible solutions to reduce administrative burdens,” said Tim Kaja, COO of UnitedHealth Networks and CAQH CORE board vice chair, in a press release.

Payers say prior authorizations serve as a check on potentially unnecessary, inappropriate, or unsafe medical treatments. For this reason, plans often require them for surgeries, diagnostic tests, procedures, and some prescriptions. However, 88 percent of prior authorizations are conducted either partially or entirely manually through an inefficient process, often by phone or fax, whereby the plan requests, and the physician provides, supporting clinical information. This process can take hours, days, and sometimes weeks before the request is ultimately approved or denied.

For providers, prior authorizations can present significant administrative and financial burdens. Providers juggle multiple health plan requirements and processes to submit a request, identify additional information that is needed, and wait for a final response.

The new rules standardize the data shared between plans and providers, eliminating unnecessary back-and-forth, decreasing wait times for a response, and freeing staff resources spent on follow-ups. Data related to the exchange of clinical information is standardized and offers providers a more consistent and predictable process across all the plans with which they participate.

According to the

CAQH Index

, adoption of the standard electronic prior authorization transaction by the industry can result in savings for both providers and payers of over 70 percent per transaction.

“Bringing the industry together to overcome administrative challenges like prior authorization are at the heart of what CAQH CORE does,” said April Todd, senior vice president, CAQH CORE, in a press release. “We have ambitious plans to further improve business processes using existing and emerging standards and encourage all industry stakeholders to engage in our multi-stakeholder efforts to accelerate automation in the healthcare system.”

CAQH CORE participating organizations represent more than 75 percent of insured Americans, including health plans, healthcare providers, vendors, government entities, and standard-setting organizations.

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