CMS Proposes Deadlines for Prior Authorization Requests in Medicare Advantage

Medicare Advantage plans would have to respond to urgent prior authorization requests for medications within 24 hours, and standard requests within 72 hours, under a proposed rule from the Centers for Medicare & Medicaid Services (CMS).

Issued Friday, the proposed rule also would require full disclosure of claims denials and appeals outcomes, according to a CMS press release. Although CMS issued a final rule on prior authorization deadlines for medical tests and procedures in February 2024 under the Biden administration, drugs were not included in it.

“Last year, we got 80% of the insurance industry to agree to eliminate prior authorization for common medical services such as diagnostic imaging, physical therapy, and outpatient surgery,” HHS Secretary Robert F. Kennedy Jr. said in the press release. “This rule builds on that agreement by making it easier for patients to get the medications they need by minimizing delays and enabling real-time decisions.”

CMS Administrator Mehmet Oz, MD, MBA, noted that “patients should not have to wait days or weeks for approval to start the medication their doctor prescribed.”

“This proposal moves prior authorization into the digital age, replacing fax machines and fragmented systems with real-time electronic workflows,” he added. “We are … ensuring providers can focus on caring for patients instead of navigating red tape.”

CMS proposed that compliance dates generally begin in 2027.

In addition to Medicare Advantage, the electronic prior authorization requirements outlined in the rule would also apply to Medicaid, the Children’s Health Insurance Program (CHIP), and health plans on the federally facilitated Affordable Care Act health insurance exchanges. Payers would have to report on approval and denial rates for drug-related prior authorizations, as well as decision time frames and outcomes of appeals, CMS said.

The agency is also proposing to require that payers support electronic prior authorization for drugs covered under a pharmacy benefit such as Part D — including three separate standards for querying formulary information and determining real-time coverage information, according to a fact sheet on the proposed rule.

In addition, plans would have to report on their use of prior authorization-related application programming interfaces — applications that outside developers can use to make it easier to interact electronically with plans. “These measures would give patients, providers, and policymakers clearer insight into how consistently and efficiently prior authorization requests are handled,” the press release noted. “Public reporting would increase accountability and make it easier to compare how plans handle prior authorization decisions.”

Finally, CMS also issued requests for information on several topics, including strengthening healthcare cybersecurity and system resilience; streamlining “step therapy” processes; and improving prior authorization for laboratory tests, durable medical equipment, prosthetics, orthotics, and supplies.

At an event in Washington Monday focused on accountable care organizations, Oz touted the progress his agency was making on easing prior authorization requirements. “I want to plug the industry, because they’re making some moves forward” on this, he said. “We’re not doing it; they’re doing it. It’s a problem that everyone agrees is an issue.”

However, he added, “the provider side of the equation is not engaging fully with the payers, and it’s harder to wrangle providers for that reason. How do you get them to realize it’s really good for you to not spend 12 hours a week in staff time — paying them [say] $30 an hour — to fight the insurance company? No one’s happy. If we can figure out a way of doing this with appropriate [computer] standards, it would make your life, your practice, much more successful.”