Health Policy News: CMS Proposes New Rule to Streamline Prior Authorization

The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule aimed at improving and streamlining prior authorization processes.
If enacted, the policies would require Medicare Advantage plans, state Medicaid and Children's Health Insurance Program (CHIP) agencies, Medicaid managed care plans, CHIP managed care entities and qualified health plan insurers on the federally facilitated exchanges to provide prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests. 

Under the provisions in the proposed rule, interoperability would be required to incentivize electronic prior authorization, and certain payers would need to provide a specific reason for denying a request. 

If finalized, the prior authorization policies in the proposed rule would take effect January 1, 2026. 

ASNC will deliver comments on the proposed rule to CMS. Stay tuned for updates.