Month: March 2024
Updated Clinical Prior Authorization
Assistance Chart Now Available
An update to the Clinical Prior Authorization Assistance Chart is available. The chart identifies which clinical prior authorization each MCO uses and whether the MCO uses all or some of the steps in the evaluation process.
New Prior Authorization Ruling Applies to Some,
But Not All.
In December 2022, I reported on a proposed rule from the Centers for Medicare & Medicaid Services (CMS) about updating requirements for prior authorization (PA), a process that many providers and patients consider to be a roadblock to obtaining care. Now, CMS has published the Final Rule (020824) on this topic, which contains significant requirements for health plans to follow to improve the process.
The rule only applies to a set of Impacted Payers: Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) Fee-for-Service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs).
Legally, these are the plans for which CMS can set requirements. However, it is expected that many commercial plans will voluntarily adopt some of these provisions.
The rule also adopts a new measure for Merit-Based Incentive Payment System (MIPS)-eligible clinicians under the Promoting Interoperability performance category of MIPS, as well as for eligible hospitals and critical access hospitals (CAHs), under the Medicare Promoting Interoperability Program.
For more information and detail, follow this link to the article written by Stanley Nachimson, MS
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