News: MACPAC approves recommendations for increased transparency on AI-supported prior authorization

The Medicaid and CHIP Payment and Access Commissions (MACPAC) approved recommendations it will issue to Congress this June. These recommendations include oversight and increased transparency of artificial intelligence (AI) usage for prior authorization.

MACPAC recommended that CMS clarify federal requirements that, for determinations of medical necessity, all adverse determinations, such as denials or reductions in requested services, must be reviewed and authorized by an individual with appropriate expertise. MACPAC also recommends that these decisions may not be made by automation tools—such as AI—alone.

The recommendations also include urging CMS to amend fee-for-service regulations to establish similar requirements and issue guidance on oversight of managed care use of automation, and that states require Medicaid health plans to disclose their use of automation. This includes testing, evaluation, and oversight.

Editor’s note: To read the full list of recommendations, click here. To read additional coverage from the American Hospital Association, click here.