CMS Issues Proposed Rule to Improve Prior Authorization Process

Last week, the Centers for Medicare and Medicaid Services (CMS) proposed a rule to expand access to health information and improve the prior authorization process, which would place new requirements on programs covered by the rule, including Medicare Advantage organizations, state Medicaid fee-for-service programs, state Children’s Health Insurance Program (CHIP) fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan issuers on the Federally-facilitated Exchanges.

The proposal would require states to maintain a Prior Authorization Requirements, Documentation and Decision (PARDD) Application Programming Interface which would automate the prior authorization process. The proposed rule would provide additional clarifications to existing Medicaid beneficiary notice and fair hearing regulations which apply to Medicaid prior authorization decisions.

ANCOR is continuing to analyze the rule and will update with relevant information. The deadline to submit comments is March 13, 2023.