New CMS Rule Proposal to Improve Access to Health Information and Streamline Prior Authorization

The US Centers for Medicare & Medicaid Services (CMS) has announced a rule proposal to streamline the prior authorization process and increase access to health information for patients and providers. The rule would require payers to share data with other payers when patients change plans. In addition, it would mandate that payers establish systems and policies that would expedite the prior authorization process.

According to CMS, “The proposed rule would address challenges with the prior authorization process faced by providers and patients. Proposals include requiring 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.”

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(Source: CMS, December 6^th, 2022)