More on Policy and Legislation

ACAP asks CMS to extend prior authorization proposed rule comment period

The group said the complexity of the proposed rule necessitates a longer window in which to conduct a thorough review.

Jeff Lagasse, Associate Editor

The Association for Community Affiliated Plans has sent a letter asking the Centers for Medicare and Medicaid Services to extend the comment period for a proposed rule regarding prior authorization processes and electronic access to health information.

Proposed earlier this month, the rule, in theory, would improve the electronic exchange of healthcare data among payers, providers and patients, and smooth out processes related to prior authorization to reduce provider and patient burden. The hope is that this increased data flow would ultimately result in better quality care.

Prior authorization – an administrative process used in healthcare for providers to request approval from payers to provide a medical service, prescription, or supply – takes place before a service is rendered. 

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The rule proposes significant changes that are intended to improve the patient experience and lessen the administrative burden prior authorization causes for healthcare providers.

Medicaid, CHIP and QHP payers would be required to build and implement FHIR-enabled APIs that could allow providers to know in advance what documentation would be needed for each different payer, streamline the documentation process, and enable providers to send prior authorization requests and receive responses electronically, directly from the provider's EHR or other practice management system. 

While Medicare Advantage plans are not included in the proposals, CMS is considering whether to do so in future rulemaking.


In its letter, ACAP expressed strong concerns with the time frames for commenting on the proposed rule. While the organization lauded CMS for its attempts to smooth the flow of health information and reduce provider burden, the group said it's infeasible for its member health plans and staff to perform the requisite evaluation of the rule, while simultaneously dealing with the ongoing COVID-19 pandemic and associated vaccine distribution efforts.

The 25-day comment period, ACAP said, is a barrier that prevents a thorough review of the proposed rule.

"ACAP agrees with some of the proposed requirements that fill a few gaps from the original Interoperability Final Rule," the group wrote in its letter. "However, much of this proposed rule is built on top of an interoperability framework that is currently in the process of being implemented; any comments on those provisions would only be conceptual as the system is not in place to know what those new proposed requirements would mean in practice."

The organization also said that changes to prior authorization processes would necessitate input from a variety of staff, including chief medical officers, utilization management, care management, provider services and compliance – requiring more time for review and comments.

"Finally, CMS requests input on five substantial areas of concern under a Request for Information (RFI) section of the rules," ACAP wrote. "ACAP agrees that these are important areas about which to gather input from health plans but, again, the truncated comment period does not allow our member plans to provide substantive input in response to those RFIs."

According to CMS, the rule would also reduce the amount of time providers wait to receive prior authorization decisions from payers. It proposes a maximum of 72 hours for payers, with the exception of QHP issuers on the FFEs, to issue decisions on urgent requests, and it proposes seven calendar days for nonurgent requests. 

Payers would also be required to provide a specific reason for any denial in an attempt to foster transparency. To promote accountability for plans, the rule also requires them to make public certain metrics that demonstrate how many procedures they are authorizing.

The rule would also require impacted payers to implement and maintain an FHIR-based API to exchange patient data as patients move from one payer to another. In this way, patients who would otherwise not have access to their historic health information would be able to bring their information with them when they move from one payer to another, and would not lose that information by changing payers.

Payers, providers and patients would presumably have access to more information, including pending and active prior authorization decisions, which would potentially allow for fewer repeat prior authorizations, for reduction in burden and cost, and for ensuring patients have better continuity of care, according to CMS.


For the American Hospital Association, the proposed rule is a mixed bag. Ashley Thompson, AHA's senior vice president of public policy analysis and development, said that hospitals and health systems are appreciative of the efforts to remove barriers to patient care by streamlining the prior authorization process.

"While prior authorization can be a helpful tool for ensuring patients receive appropriate care, the practice is too often used in a manner that leads to dangerous delays in treatment, clinician burnout and more waste in the healthcare system," she said in a statement. "The proposed rule is a welcome step toward helping clinicians spend their limited time on patient care."

Yet the AHA expressed regret on one point in particular.

Thompson said the AHA is disappointed that CMS "chose not to include Medicare Advantage plans, many of which have implemented abusive prior authorization practices, as documented in our recent report. We urge the agency to reconsider and hold Medicare Advantage plans accountable to the same standards."


The rule builds on the Interoperability and Patient Access Final Rule released earlier this year.

The rule requires payers in Medicaid, CHIP and QHP programs to build application programming interfaces to support data exchange and prior authorization. APIs allow two systems, or a payer's system and a third-party app, to communicate and share data electronically.

Payers would be required to implement and maintain these APIs using the Health Level 7 (HL7) Fast Healthcare Interoperability Resources standard. The FHIR standard aims to bridge the gaps between systems using technology so both systems can understand and use the data they exchange.


"The proposed rule contains numerous new and complex policies that could require a significant investment of time and resources to design and integrate into our systems and operational practices," ACAP wrote. "It is critical that CMS allows for a thoughtful review by those affected by the proposed changes so that meaningful feedback can be provided."

Twitter: @JELagasse
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