News and Publications

ASTRO urged the Centers for Medicare and Medicaid Services (CMS) to finalize proposed requirements for electronic standardization of prior authorization (PA) for all Medicare and Medicaid payers in a letter sent March 9. The letter supports CMS’ proposal to establish Application Programming Interface (API) Implementation Guides (IG) for patients and providers, as well as a payer-to-payer data exchange API. Should CMS move to finalize the proposed rule, it will:

• Require payers to include information about PA decisions, including a specific reason for denials, in the patient access API.
• Allow for the exchange of patient information between payers, such as when a patient changes insurance.
• Allow for the exchange of patient data between payers and providers, including adjudicated claims and encounters data, and patient PA decisions.
• Establish a PA turnaround time requirement of seven days for standard cases and 72 hours for urgent cases.

What’s Next: ASTRO is hopeful CMS will move to finalize this proposed rule and appreciates CMS’ recognition that burdensome PA needs reform. While ASTRO continues to advocate for improving PA through legislation, these regulatory changes would address many of the concerns ASTRO has voiced over the years about PA processes in Medicare Advantage.