ESSENTIA HEALTH

Prior Authorization Simplification - H.R. 8702/S. 4532 - Improving Seniors Timely Access to Care Act Establish an electronic prior authorization process for MA plans including a standardization for transactions and clinical attachments. Increase transparency around MA prior authorization requirements and its use. Clarify CMS authority to establish timeframes for e-PA requests including expedited determinations, real-time decisions for routinely approved items and services, and other PA requests. Expand beneficiary protections to improve enrollee experiences and outcomes. Require HHS and other agencies to report to Congress on program integrity efforts and other ways to further improve the e-PA process.

Finding streamlined solutions for prior authorization. Prior authorization is a health plan cost-control process that requires providers to qualify for payment by obtaining approval before performing a service. For Medicare patients, prior authorization is much more prevalent in Medicare Advantage plans.