March 11, 2024
Payers | Tea Leaves
  • To combat growing criticism of prior authorization delays by payers, the Centers for Medicare & Medicaid Services (CMS) finalized a rule Wednesday that requires health plans to send prior authorization decisions within three days for urgent requests and seven days for standard requests starting in 2026. The guidelines will affect Medicare Advantage, Medicaid, the Children’s Health Insurance Program, Medicaid managed care, and qualified health plans. It also requires payers to give patients and providers a reason for denying a prior authorization request and instruct the other party on how to resubmit the request or appeal the decision. Payers will be required to implement an application programming interface to support a better, more efficient electronic automation process. (Articles herehereherehere, and here; Press release here)