On Dec. 6, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule requiring Medicare Advantage (MA), Medicaid, the Children’s Health Insurance Program (CHIP), and federally facilitated marketplace health plans to streamline processes related to prior authorization and to improve electronic exchange of health care data.
Specifically, effective Jan. 1, 2026, the rule would require payers to build and maintain an application programming interface to automate the process, to identify prior authorization information and documentation requirements, and to facilitate the exchange of prior authorization requests and decisions from electronic health records or systems. Payers would be required to send prior authorization decisions within 72 hours for expedited (urgent) requests and seven calendar days for non-urgent requests and would be required to include a specific reason for denials. The rule would also create a new electronic prior authorization measure in the Merit-based Incentive Payment System and the Medicare Promoting Interoperability Program to encourage adoption of the technology by clinicians and hospitals.
This is the revised version of a rule [refer to Washington Highlights Jan. 8, 2021] originally released in December 2020 that was withdrawn. That rule only applied to Medicaid managed care, CHIP, and the federally facilitated marketplace, while the new version would also apply to those programs and to MA plans as well.
Other provisions in the rule would require that payers exchange patient data when a patient changes health plans, with the patient’s permission, to ensure that a patient’s data follows them throughout their care. In the rule, the CMS issued several requests for feedback on how to improve electronic exchange of Medicare fee-for-service information and how to accelerate adoption of standards to collect and send social risk factor data.
The AAMC will review the rule in detail and submit comments by the March 13, 2023 comment deadline.