Skip to main content

In this review; Medicaid Program; Patient Protection and Affordable Care Act; Reducing Provider and Patient Burden by Improving Prior Authorization Processes, and Promoting Patients’Electronic Access to Health Information for Medicaid Managed Care Plans, State Medicaid Agencies, CHIP Agencies and CHIP Managed Care Entities, and Issuers of Qualified Health Plans on the Federally-facilitated Exchanges; Health Information Technology Standards and Implementation Specifications (proposed rule)
Comment deadline: Jan. 4, 2021
Effective date: Jan. 1, 2023
CMS Fact Sheet

The big picture: CMS wants to make prior authorization decisions more transparent, with speedier turnaround times.

Prior authorization requirements, never a favorite among health care providers, may be getting a little easier to deal with under Medicaid, the Children's Health Insurance Program, and qualified health plans on federal health insurance exchanges, thanks to a proposed rule from the U.S. Centers for Medicare & Medicaid Services. If adopted, the rule would require beefed-up technology, the publication of payer metrics on prior authorization decisions, and time limits on how long payers can take to respond to prior authorization requests. The proposed changes, largely supported by APTA, are aimed at creating more transparency in the system, and to make prior authorization operations more consistent with interoperability rules put in place this spring. The new requirements would take effect in 2023.

Log in or create a free account to keep reading.


Join APTA to get unlimited access to content.


You Might Also Like...

News

Anthem's UM Arm Releases Guidelines on Clinical Appropriateness

Feb 5, 2021

Included: lists of what is and isn't considered medically necessary under Anthem's MA, Medicaid, and commercial offerings.

News

Payment Win: Aetna Becomes Second Major Insurer to Lift Edits on Code Pairs

Feb 5, 2021

The major commercial insurer follows Cigna in a decision to lift misguided coding edits, a target of APTA advocacy efforts.

Article

Code Pairing Edits: Four Things To Know

Jan 25, 2021

APTA successfully advocated for CMS to lift misguided coding edits, and we're working to bring commercial payers around.