The Centers for Medicare and Medicaid Services (CMS) wants to change the length of time it takes for access to critical treatments under the Interoperability Standards and Prior Authorization for Drugs proposed rule.

The proposal “would advance sweeping reforms to modernize prior authorization for drugs by establishing clear decision deadlines for impacted payers – no later than 24 hours for urgent requests and 72 hours for standard requests – and increasing transparency through full disclosure of claims denials and appeals outcomes,” the agency said.

CMS Administrator Dr. Mehmet Oz stressed that the proposal moves prior authorization into the digital age, replacing fax machines and fragmented systems with real-time electronic workflows.

Building on CMS’s 2024 Interoperability and Prior Authorization final rule, which addressed prior authorization for non-drug items and services, this new draft seeks to ensure patients experience the same streamlined process for medications as other covered services.

The rule would expand electronic prior authorization requirements to include drugs, aligning processes across Medicare Advantage, Medicaid, the Children’s Health Insurance Program, Qualified Health Plans (QHP) issuers on the Federally-facilitated Exchanges, and Small Group Market QHPs on the Federally-facilitated Small Business Health Options Program.

Impacted payers would also be required to publicly report prior authorization metrics for drugs, including:

• Approval and denial rates;

• Appeal outcomes; and

• Decision time frames.

CMS said it wants compliance dates generally beginning in 2027.

Comments or questions? Contact Patrick Connole at pconnole@parkplacelive.com.