News: CMS proposes deadlines for drug prior auth requests for Medicare Advantage plans

Under a new proposed rule from CMS, Medicare Advantage plans would have to respond to urgent prior authorization requests for medications within 24 hours and standard requests within 72 hours.

The rule also proposes a full disclosure of claims denials and appeals outcomes. Although CMS issued a final rule on prior authorization deadlines for medical tests and procedures in February 2024, drugs were not included in it. CMS proposed for the compliance dates to begin in 2027 generally, with no specific date.

Beyond Medicare Advantage, the electronic prior authorization requirements that the rule proposed would also apply to Medicaid, the Children’s Health Insurance Program (CHIP), and health plans on the federally facilitated Affordable Care Act health insurance exchanges.

Payers would have to report on approval and denial rates for drug-related prior authorizations as well as decision time frames and outcomes of appeals. Plans would be required to report on their use of prior-authorization applications that outside developers can use to make it easier to electronically interact with plans.

The agency is also proposing requiring that payers support electronic prior authorization for drugs covered under a pharmacy benefit, such as Part D. This includes three separate standards for querying formulary information and determining real-time coverage information.

CMS also requested information on several topics, including:

• Strengthening healthcare cybersecurity and system resilience
• Streamlining “step therapy” processes
• Improving prior authorization for laboratory tests, durable medical equipment, prosthetics, orthotics, and supplies

CMS Administrator Mehmet Oz, MD, MBA, noted that “patients should not have to wait days or weeks for approval to start the medication their doctor prescribed.”

“This proposal moves prior authorization into the digital age, replacing fax machines and fragmented systems with real-time electronic workflows," he added. "We are [...] ensuring providers can focus on caring for patients instead of navigating red tape.”

Editor’s note: To read the full proposal, click here. To read additional coverage by MedPage Today, click here.