Prior Authorization Process: Mandates for Health Plans

New CMS rule offers a breather for orthopaedic surgeons (and their patients) from chronic prior authorization miseries


After publishing a proposed rule more than a year ago, CMS recently finalized a rule to streamline the prior authorization process that establishes whether a requested medical service will be covered by health insurance. Shortened prior authorization timelines, reporting requirements for coverage denials, and a new Fast Healthcare Interoperability Resources application programming interface (FHIR API) are designed to increase the efficiency and transparency of the prior authorization process. The Advancing Interoperability and Improving Prior Authorization Processes rule also requires health plans to put technology in place to improve the electronic exchange of health data for physicians. The rule applies to Medicare Advantage organizations, Medicaid managed care programs, and plans that offer individual health plans on CMS also established incentives for physicians to use the new Prior Authorization API.