ASH has written to the Centers for Medicare & Medicaid Services in response to that agency’s proposed regulation, published last December, to establish new prior authorization requirements for Medicare Advantage organizations, state Medicaid fee-for-service programs, state Children’s Health Insurance Program (CHIP) fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plans.
In its letter on behalf of community safety-net hospitals, ASH:
- Supported a CMS proposal to automate the prior authorization process but urged CMS to ensure that the documentation requirements imposed by payers are not excessively burdensome and adddress only whether a patient’s condition meets criteria for approval. ASH also urged CMS to require payers to use criteria developed by professionals with the education and experience needed to play such an important role in this process.
- Agreed with the CMS proposal to require payers to give a specific reason for denying requests for prior authorization.
- Endorsed CMS’s proposal to require payers to make and transmit prior authorization decisions within a specified period of time – but disagreed with CMS about what those time periods should be. ASH urged CMS to adopt a standard of a 24-hour response for expedited requests for prior authorization and 48 hours for standard prior authorization requests.
- Urged CMS to include in its final regulation a provision that calls for automatic approval for any prior authorization request not addressed by payers within established time limits.
Learn more about what CMS proposed and how ASH responded to that proposal in this ASH letter to CMS.
