Prior Authorization and Administrative Simplification

Electronic prior authorization rules, API requirements and decision timelines, plus the transaction standards and paperwork burden underneath them.

Prior authorization is now two policy problems that are usually discussed as one. The first is timing and transparency: how fast a payer must decide, what it must disclose, and what it must report. The second is plumbing: whether the request moves through an API that connects to the physician's workflow, or through a fax machine wearing a portal.

Rules that fix the first without the second reduce the wait but not the work. That distinction is the most useful thing to hold onto when reading any announcement in this area, including a voluntary payer commitment.

What this covers

CMS interoperability and prior authorization rulemaking, including API requirements, decision timelines, denial reporting and the compliance dates attached to each. Electronic prior authorization standards work at HL7 and X12 and the tension between them. Payer pledges and voluntary reductions, read against what is actually enforceable. HIPAA administrative simplification transaction standards and operating rules. Paperwork Reduction Act notices, which is where burden estimates for all of this are argued in public.

Why it is hard to track

The obligations are staged: an API requirement, a reporting requirement and a timeline requirement from the same rule frequently take effect in different years. A payer announcement that sounds like relief can also leave the underlying documentation requirement intact, which is visible only if you compare the announcement with the rule it sits on top of.

In this area

24 briefs, newest first. Tag archives: Prior Authorization · Administrative Simplification

Dates that bind

Open comment windows and effective dates are on the regulatory tracker, which regenerates every weekday. Compliance dates are on the compliance page. Verify any date you intend to rely on against the primary document linked in the brief; see disclosures for how these briefs are produced.