CMS Proposed a Rule for Improving Prior Authorizations Our billing experts are well versed with the prior authorizations process for various insurance carriers ensuing accurate collection of insurance reimbursements. To know more about our prior authorization services or overall medical billing and coding services, contact us at info@medicalbillersandcoders.com/ 888-357-3226 Click Here: https://bit.ly/3uUaAyB #CMS #improvingpriorauthorizations #priorauthorizations #priorauthorizationsprocess #reimbursements #priorauthorizationservices #medicalbilling

1. CMS Proposed a Rule for
Improving Prior
Authorizations
Medical Billers and Coders

2. CMS recently proposed a rule to improve prior authorizations processes by
reducing the burden on providers and patients. This proposed rule would
place new requirements on Medicaid and CHIP managed care plans, state
Medicaid and CHIP fee-for-service programs, and Qualified Health Plans
(QHP) issuers on the Federally-facilitated Exchanges (FFEs) to improve the
electronic exchange of health care data, and streamline processes related to
prior authorization. The rule would require increased patient electronic
access to their health care information and would improve the electronic
exchange of health information among payers, providers, and patients.
Together, these policies would play a key role in reducing overall payer and
provider burden and improving patient access to health information. This
rule includes five sets of proposals and five requests for information. These
prior authorization policies are proposed to take effect on January 1, 2023,
with the initial set of metrics proposed to be reported by March 31, 2023. In
this article, we shared only one proposal named ‘Documentation and Prior
Authorization Burden Reduction through APIs’

3. Documentation and Prior Authorization Burden Reduction through APIs
Prior authorization is an administrative process used in healthcare for
providers to request approval from payers to provide a medical service,
prescription, or supply. The prior authorization request is made before
those medical services or items are rendered. While prior authorization
has its benefits, patients, providers, and payers alike have experienced
burdens from it. And, it has been identified as a major source of provider
burnout. Providers expend staff resources to identify prior authorization
requirements and navigate the submission and approval processes,
resources that could otherwise be directed to clinical care, and processes
that vary across payers. Patients may unnecessarily pay out-of-pocket or
abandon treatment altogether when prior authorization is delayed. In an
attempt to alleviate some of the administrative burdens of prior
authorization and to improve the patient experience, CMS is proposing a
number of policies to help make the prior authorization process more
efficient and transparent.

4.  Document Requirement Lookup Service (DRLS) API: CMS is
proposing to require impacted payers to build and maintain an FHIR-
enabled DRLS API, that could be integrated with a provider’s electronic
health record (EHR)- to allow providers to electronically locate prior
authorization requirements for each specific payer from within the
provider’s workflow.
 Prior Authorization Support (PAS) API: CMS is proposing to require
impacted payers to build and maintain an FHIR-enabled electronic Prior
Authorization Support API that has the capability to send prior
authorization requests and receive responses electronically within their
existing workflow (while maintaining the integrity of the HIPAA
transaction standards).
 Denial Reason: CMS is proposing to require impacted payers to include
a specific reason for denial when denying a prior authorization request,
regardless of the method used to send the prior authorization decision, to
facilitate better communication and understanding between the provider
and payer.

5.  Shorter Prior Authorization Timeframes: CMS is proposing to
require impacted payers (not including QHP issuers on the FFEs) to
send prior authorization decisions within 72 hours for urgent requests
and 7 calendar days for standard requests.
 Prior Authorization Metrics: CMS is proposing to require impacted
payers publicly report data about their prior authorization process, such
as the percent of prior authorization requests approved, denied, and
ultimately approved after appeal, and the average time between
submission and determination, to improve transparency into the prior
authorization process, which will help patients understand.

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