(Jan. 19, 2024) – This week, the Centers for Medicare & Medicaid Services released a final rule requiring Medicare Advantage, Medicaid and federally facilitated Marketplace plans to streamline their prior authorization processes. The Kansas Hospital Association has advocated with the agency during the past year to finalize this rule to alleviate provider burden and ensure timely access to care for patients. The new rule removes barriers to patient care by streamlining the prior authorization process, creates interoperable prior authorization standards, and requires more transparency and timeliness from payers on their prior authorization decisions. The final rule:
- Requires payers to implement and maintain certain Health Level 7 Fast Healthcare Interoperability Resources application programming interfaces to improve the electronic exchange of health care data, generally beginning Jan. 1, 2027.
- Adds a new measure for Merit-based Incentive Payment System eligible clinicians under the Promoting Interoperability performance category of MIPS, as well as for eligible hospitals and Critical Access Hospitals, under the Medicare Promoting Interoperability Program. This will incentivize providers to utilize these electronic interfaces.
- Payers must implement certain operational provisions, generally beginning Jan. 1, 2026.
- Payer-to-Payer interfaces requiring payers to share patient information about certain prior authorizations when a patient switches insurance.
- Payers must implement and maintain a prior authorization interface that is populated with its list of covered items and services and prompts providers on what documentation requirements are needed for prior authorization approval and supports the prior authorization request and response. The interface will communicate whether the payer approves the request and the specific reason for the denial. This must be implemented beginning Jan. 1, 2027.
- New prior authorization decision timeframes were established including 72 hours for urgent requests and seven calendar days for standard requests.
- Payers must publicly report certain prior authorization metrics annually by posting them on their website. The compliance date is Jan. 1, 2026.
Overall, KHA is pleased with the announcement and looks forward to working with the new streamlined approaches in the coming years.
--Shannan Flach