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Health insurers face a prior authorization prescription drug mandate similar to the rule imposed on claims, under a proposal released Friday by the Centers for Medicare & Medicaid Services.
CMS is proposing to require payers to support electronic prior authorization and to make decisions on requests within a shorter timeframe, in the 2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule.
A 2024 final rule focused on prior authorization of non-drug items and services. That timeframe is seven days for standard requests and 72 hours for expedited requests. The new proposed rule extends many of these requirements to cover prior authorizations for drugs.
Certain insurers would be required to make prior authorization decisions for covered outpatient drugs no later than 24 hours after receiving a prior authorization request.
CMS proposes compliance dates beginning Oct. 1, 2027.
In addition, CMS is proposing to require payers to update health information technology standards and to report interoperability API endpoints and API usage metrics.
This proposed rule builds on the 2020 CMS Interoperability and Patient Access final rule and the 2024 CMS Interoperability and Prior Authorization final rule, which together require Medicare Advantage organizations, state Medicaid and Children's Health Insurance Program (CHIP) fee-for-service programs, Medicaid managed care plans, CHIP managed care entities and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges to implement Patient Access, Provider Directory, Provider Access, Payer-to-Payer and Prior Authorization Application Programming Interfaces (APIs).
Email the writer: SMorse@himss.org