- What must be included in the impacted payer’s prior authorization decision response via the Prior Authorization API?
The final rule did not include a requirement for impacted payers to use the Prior Authorization API to make real-time decisions on prior authorization requests, but the automation that the API provides could improve decision timeframes. Though we anticipate that some responses or decisions may be made in real-time, other decisions will continue to necessitate review and evaluation by clinical reviewers (the CMS Interoperability and Prior Authorization final rule requires impacted payers, excluding QHP issuers on the FFEs, to send decisions within 72 hours for expedited [i.e., urgent] requests and seven calendar days for standard [i.e., non-urgent] requests). Automating a complex process such as prior authorization will be an ongoing process of continuous improvement.
- How does the rule change the timeframe requirements for responses to prior authorization requests?
We are requiring impacted payers to send prior authorization decisions to providers within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests.
- Will impacted payers be required to report prior authorization metrics at the plan level? Will they be reporting these metrics for each item or service furnished?
We are requiring impacted payers to annually report certain prior authorization metrics, MA organizations at the organization level, state Medicaid and CHIP FFS programs, Medicaid managed care plans, and CHIP managed care entities at the state level, and QHP issuers on the FFEs to report at the issuer level, by posting them on their public website. These metrics include a list of all items and services that require prior authorization, as well as other aggregated metrics for all items and services.
- Are impacted payers required to make real-time decisions on prior authorization requests?
The final rule did not include a requirement for impacted payers to use the Prior Authorization API to make real-time decisions on prior authorization requests, but the automation that the API provides could improve decision timeframes. Though we anticipate that some responses or decisions may be made in real-time, other decisions will continue to necessitate review and evaluation by clinical reviewers (the CMS Interoperability and Prior Authorization final rule requires impacted payers, excluding QHP issuers on the FFEs, to send decisions within 72 hours for expedited [i.e., urgent] requests and seven calendar days for standard [i.e., non-urgent] requests). Automating a complex process such as prior authorization will be an ongoing process of continuous improvement.