Premier Comments on CMS’ Proposed Rule to Improve Prior Authorization and Expand Interoperability

Premier submitted comments to the Centers for Medicare & Medicaid Services (CMS) on its proposed rule to advance interoperability and improve prior authorization processes across CMS-regulated health programs. The proposed rule seeks public comment on CMS’ proposals to ensure timely access to care and improve data sharing among Medicare Advantage (MA) organizations, Medicaid managed care plans, the Children’s Health Insurance Program (CHIP) and issuers of Qualified Health Plans (QHPs) on the federally-facilitated Exchanges.

In its comments, Premier expresses appreciation for CMS’ commitment to improving access to care and enabling better data exchange among providers, patients and payers. Specifically, Premier recommends that CMS:

• Require payers to disclose via Patient Access application programming interfaces (APIs) the specific coverage criteria that were and were not satisfied for prior authorization requests that result in denials;
  
• Finalize proposed requirements for payers to build and maintain Provider Access APIs, while ensuring that patient data collected by vertically-integrated, payer-owned providers and health services companies is included in the available data;
• Require that data received by payers through the payer-to-payer data exchange be shared on the Provider Access API so that providers have access to longitudinal data on patients’ healthcare and can provide the most appropriate care;
• Finalize proposed requirements for affected payers to build and maintain Prior Authorization Requirements, Documentation, and Decision (PARDD) APIs, creating a single electronic point of entry for the payer’s prior authorization processes that holds potential for integrating into the provider workflow;
• No later than 12 months following the publication of a final rule, require affected payers to deliver prior authorization responses within 72 calendar hours for standard, non-urgent services and within 24 calendar hours for urgent services; and
• In the longer term, develop programs to provide affected payers with additional flexibilities and/or financial rewards for implementing real-time prior authorization programs with contracted providers.