Biden Administration Finalizes Prior Authorization Rule

The Biden administration finalized a rule that will simplify Medicare Advantage, Medicaid, and other government-sponsored health plans’ use of prior authorization. Having the government finally address prior authorization is a win; however, the Society of Nuclear Medicine & Molecular Imaging (SNMMI) continues to fight inappropriate denials and reimbursement issues.

 The rule, finalized on January 17, 2024, requires government-sponsored health plans to have a quicker response time to prior authorization requests. The rule will also require government-sponsored health plans to inform recipients of the reason for denied requests.

Starting in 2026, the affected health plans will be required to:

• Reply to urgent requests within three days and non-urgent requests within seven days.
• Respond to any denied prior authorization decision regardless of the way the request was received.

In 2027, several other provisions will be required:

• Develop application programing interfaces (APIs) that enable providers to decide if prior authorization is necessary and to automate the release of denial information. Among the APIs slated for development, the Patient Access and Provider Access APIs are the most significant.
• The Patient Access API enhances a patient’s ability to access and view their data; this allows for a patient to have a deeper understanding of the prior authorization process and the potential impacts to their care.
• The Provider Access API allows health plans to share information with in-network clinicians who patients visit.