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ACC Grassroots Efforts Usher in Major Prior Auth Win

The final Centers for Medicare and Medicaid Services (CMS) Interoperability and Prior Authorization Rule released this month marks a major milestone in reforming prior authorization practices and reflects the ongoing work of ACC Advocacy to reduce prior authorization burden on clinicians.

Changes incorporated in the final rule will help minimize avoidable delays in care and decrease administrative burden for clinicians, applying to Medicare Advantage, Medicaid and Children’s Health Insurance Program payers and providers beginning in 2026 and 2027.

Notable changes from the final rule include:

  • Tighten timelines for payers to respond to urgent (72 hours) and non-urgent (7 days) PA requests.
  • Increase transparency by requiring payers to publicly report metrics, including approval and denial rates and average review timeframes.
  • Streamline electronic prior authorization requests by requiring payers to implement and maintain a prior authorization application programming interface.

Prior authorization reform has been a priority issue for ACC and the broader health care community for years. In the past year, ACC members sent more than 1,000 messages to state and federal lawmakers and met with over 300 congressional offices during ACC’s 2023 Legislative Conference to move the needle on prior authorization reform.

For more on ACC Advocacy wins from the past year along with a preview of what to expect in the near future, access ACC Advocacy’s 2023 Recap & Look Ahead to 2024 and ACC’s Vision For Championing Patient Access to Care.

Keywords: Electronics, Health Services Accessibility, Prior Authorization, Medicare Part C, Medicaid, Centers for Medicare and Medicaid Services, U.S., United States, ACC Advocacy

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