CMS opens data comment, reforms prior auth

The Centers for Medicare & Medicaid Services opened a public comment window on April 27 for a data-collection package tied to prior authorization oversight. (federalregister.gov) The notice, listed as CMS-10945, gives the public until May 27, 2026, to comment under the Paperwork Reduction Act on how CMS plans to collect and review reporting data. (federalregister.gov) That filing lands two weeks after CMS proposed a broader rule to remake prior authorization for prescription drugs across Medicare Advantage, Medicaid, the Children’s Health Insurance Program, and federally facilitated exchange plans. (cms.gov 1) (cms.gov 2) CMS said the April 10 proposal would require impacted payers to return urgent drug prior-authorization decisions within 24 hours and standard requests within 72 hours, while publicly reporting approval rates, denial rates, appeal outcomes, and decision times. (cms.gov) The agency is also pushing the process away from fax and phone calls and toward application programming interfaces, or software connections that let systems exchange prior-authorization data automatically. (cms.gov) In parallel, major insurers led by AHIP and the Blue Cross Blue Shield Association said April 25 they will align electronic data-submission requirements for common medical services subject to prior authorization, including orthopedic surgeries, computed tomography scans, and magnetic resonance imaging, beginning January 1. (healthcaredive.com) (ahip.org) That insurer effort is part of a June 2025 voluntary pledge with federal officials. AHIP said participating plans cover nearly 270 million Americans and are working toward a broader standardized electronic framework by January 1, 2027. (ahip.org 1) (ahip.org 2) Insurers and their trade groups say incomplete provider submissions are a major reason requests stall, and they argue common electronic formats should reduce resubmissions and speed determinations. (healthcaredive.com) (ahip.org) Providers have been more skeptical. Healthcare Dive reported earlier this month that insurers said they had eliminated 11% of prior authorizations, equal to 6.5 million fewer requests, but physician groups have questioned whether voluntary commitments will produce durable change. (healthcaredive.com) The immediate next deadline is May 27 for comments on CMS’s reporting package, while the broader drug prior-authorization proposal remains open for public comment until June 15. (federalregister.gov) (cms.gov)