CMS Finalizes Prior Authorization Reform

On Jan. 17, the Centers for Medicare & Medicaid Services (CMS) finalized rules streamlining prior authorization in Medicare Advantage, state Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service, Medicaid managed care, CHIP managed care and Qualified Health Plans on the federal exchange. The final rule requires, among other things, covered plans to:

  • Implement an electronic prior authorization process;
  • Reduce care delays by responding to prior authorization requests within 72 hours for urgent requests and seven days for standard requests; and
  • Report the use of prior authorization, including specific reasons for denials and other prior authorization metrics.

Following the rule’s publication, the Regulatory Relief Coalition, of which the AANS and the CNS are leaders, issued a press release lauding CMS for its finalized landmark rule. “This is a watershed moment for patients’ access to care,” said Russell R. Lonser, MD, FAANS, chair of the department of neurosurgery at The Ohio State University and chair of the AANS/CNS Washington Committee. He added, “The rampant overuse of prior authorization, particularly in Medicare Advantage, continues to cause inappropriate delays and denials of medical treatments that our seniors need.”

Click here for a CMS fact sheet on the rule and here for the agency’s press release.