New Centers for Medicare and Medicaid Services (CMS) Rule Addresses Prior Authorization Process

New Centers for Medicare and Medicaid Services (CMS) Rule Addresses Prior Authorization Process

A new CMS rule allows for certain payers (including Medicaid, the Children’s Health Insurance Program (CHIP) and exchange plans), providers and patients to have electronic access to pending and active prior authorization decisions, intended to result in fewer repeated requests for prior authorizations and reduce costs and administration burden to front-line providers. Specifically, the rule would, “allow providers to know in advance what documentation each payer would require, streamline documentation processes and make it easier for providers to send and receive prior authorization information requests and responses electronically.” The rule provides for Medicaid and CHIP fee-for-service and managed care plans to have up to 72 hours to make prior authorization decisions on urgent requests and seven calendar days for nonurgent requests, and covered payers must provide a specific reason for any denials.
 
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