CMS Publishes Interoperability and Prior Authorization Final Rule: What It Will Mean for Patient Access

Plans argue the practice is needed to prevent inappropriate use of services and to save the health system money, while providers and patients argue that prior authorization is an onerous and often arbitrary barrier to necessary care and treatment. [...] The new rule adds to those requirements by requiring payers to add information about prior authorizations (excluding those for drugs) to the data available via that Patient Access API (in addition to the Prior Authorization API mechanism discussed below). [...] • Prior Authorization API: Payers must provide prior authorization information to patients and providers through a new Prior Authorization API, which includes information on covered items and services and what documentation is required for prior authorization request. [...] The API must also make a more limited set of data on prior authorization available to other payers to help ensure continuity of care and treatment when patients transition to a new plan. [...] Payers must also provide health plan enrollees with information regarding the plan’s prior authorization policies, including items and service subject to prior authorization, the timeframes in which decisions about prior authorization will be made, the criteria by which the payer will make a decision regarding prior authorization, and how a beneficiary or enrollee can appeal a prior authorization.