News: CMS issues updated prior authorization reporting guidance

CMS released updated guidance that strengthens federal transparency requirements for prior authorization.

The CMS Interoperability and Prior Authorization final rule published in 2024 requires payers to publicly post prior authorization requirements and outcomes with a three-day deadline for urgent requests and a seven-day deadline for standard requests.

Under the changes from CMS, payers impacted by the Interoperability and Prior Authorization final rule must publicly report certain prior authorization metrics from the previous calendar year by posting them on their websites. Payers impacted by this update include:

• Medicare Advantage (MA) organizations
• State Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs
• Medicaid managed care plans
• CHIP managed care entities
• Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs)

The updated metrics reporting framework clarifies that posting required metrics only through password-protected portals or “other locations that cannot be reached through ordinary navigation from the payer’s public-facing website” does not satisfy the rule’s “publicly accessible” requirement.

CMS recommended that the metrics be presented in a meaningful way to patients and providers in clear, visual formats such as bar charts or pie charts. The rule also recommended reporting both counts and percentages so the public can understand the scope of requests.

In addition, “all turnaround time metrics must include explicit time units (hours or calendar days), and median turnaround times of less than one calendar day must be reported in hours rather than rounded to ‘0 days,’ ” the update wrote.

CMS now also specifies that plans must publicly identify all medical items and services requiring prior authorization and identification of entire categories of care from disclosures.

The American Medical Association (AMA), welcoming the updated guidance that strengthens federal transparency requirements for prior authorization, also flagged remaining gaps in the framework. These include:

• Defining prior authorization broadly enough to “capture rebranded practices”
• Making information available at the point of enrollment
• Standardizing prior authorization reporting

Editor’s note: To read the updated guidance, click here. To read additional coverage from Fierce Healthcare, click here.