The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would improve patient and provider access to health information and streamline processes related to prior authorization for medical items and services.
The proposed rule includes requirements for certain payers to include a specific reason when denying requests, publicly report certain prior authorization metrics, and send decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests.
Proposed policies in this rule would also enable improved access to health data, supporting higher-quality care for patients with fewer disruptions. The policies include: expanding the current Patient Access API to include information about prior authorization decisions; allowing providers to access their patients’ data by requiring payers to build and maintain a provider access FHIR API, to enable data exchange from payers to in-network providers with whom the patient has a treatment relationship; and creating longitudinal patient records by requiring payers to exchange patient data using a payer-to-payer FHIR API when a patient moves between payers or has concurrent payers.
The requirements would generally apply to Medicare Advantage organizations, state Medicaid and Children’s Health Insurance Program (CHIP) agencies, Medicaid managed care plans, CHIP managed care entities, and qualified health plan issuers on the federally facilitated exchanges, promoting alignment across coverage types. CMS estimates that efficiencies introduced through these policies would save physician practices and hospitals over $15 billion over a ten-year period.
To read the proposed rule, visit the CMS website. The deadline to submit comments is March 13, 2023.
