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CMS Issues New Rules to Streamline Prior Authorization

In mid-January, the Centers for Medicare & Medicaid Services finalized a regulation aimed at streamlining prior authorization (PA) processes and improving patient and provider access to electronic health information. The rule applies to Medicaid, CHIP and exchange plans. Under the new regulations, plans would have 72 hours to make prior authorization determinations and seven calendar days for standard requests. The rule would also require health plans to provide specific reasons for denials and publicly report metrics that demonstrate how they operationalize their PA processes.

The AANS and the CNS had commented on the proposed rule, joining both the Alliance of Specialty Medicine and the Regulatory Relief Coalition in expressing general support for these policies. The groups also requested that CMS expand the rule to cover Medicare Advantage plans and to include prescription drugs and covered outpatient drugs among the services subject to the new requirements.

Despite its publication, based on an order issued by the president’s chief of staff, Ronald A. Klain, the Biden Administration is currently conducting a regulatory freeze pending review. These new rules may therefore be modified before going into effect.