Last week CMS issued its final rule “CMS Interoperability and Prior Authorization” (CMS-0057-F), unchanged from its proposed rule in 2022, which addresses prior authorizations. Prior authorization, a “utilization management” technique, requires a health insurer to consent to a doctor’s proposed course of treatment for a patient before the insurer agrees to pay for any medical services the physician wishes to provide. See July 2023 Health Law Informer Article.

On January 17, 2024, CMS issued the rule which requires certain health plans to decide prior authorization requests within 72 hours for expedited requests and seven days for non-urgent appeals. The rule applies to Medicare, Medicare Advantage (MA), Medicaid, and Children’s Health Insurance Plans (CHIP), as well as qualified health plans on the Federally-Facilitated Exchanges (collectively, “Covered Entities”). [cite] In addition to the decision timeframe requirements, the rule also requires payers to provide a specific reason for denied prior authorization requests, and allows such decisions to be communicated via portal, fax, email, mail or phone. [cite] The rule does not apply to prior authorization decisions for drugs. [cite]