Prior Authorization API

What must be included in the impacted payer’s prior authorization response via the Prior Authorization Application Programming Interface (API)? 

Under CMS-0057-F, an impacted payer’s response to a prior authorization request must do one of three things: approve the request and specify the date or circumstance under which the authorization ends; deny the request and provide a specific reason for the denial; or request additional information needed to make a decision. 

Note: Through its recent proposed rule CMS-0062-P, CMS is proposing updates to the requirements for reporting of prior authorization decisions and API usage metrics. For further information, please refer to the Fact Sheet.