Group stakes out 2-day time limits to speed prior auth process

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A group representing many stakeholders within the healthcare industry is pushing to set time requirements intended to speed the prior authorization process.

This week, CAQH CORE voted to set a two-day time limit for health plans to request additional supporting information from providers and make a final determination on prior authorization requests.

Such a time limit would address at least part of the process by which health plans seek information from providers to verify the medical necessity of a procedure or plan of treatment for a patient. While the plans say it’s essential for them to have a process by which they can review care in advance, providers say it’s overly burdensome and unnecessarily delays patient care that may be time-sensitive.

The vote by the CAQH CORE board is significant because it sets a guideline for plans to make determinations on provider requests. It is a multi-stakeholder organization representing providers, health plans, vendors and government entities. CAQH CORE executives say the group’s imprimatur affects more than 80 percent of the healthcare industry’s stakeholders.

“Prior authorizations serve as a check on the safety and appropriateness of medical treatments, but when they take too long, they can delay patient care,” said Susan Turney, MD, CEO of Marshfield Clinic Health System and the chair of the CAQH CORE board. “With today’s announcement, the industry has reached a compromise to ensure they are done efficiently.”

Under the new operating rule, CAQH CORE participating organizations agree to update requirements in the CAQH CORE 278 Prior Authorization Infrastructure Rule. The new requirements set national expectations for prior authorization turnaround times using the HIPAA-mandated standard to move the industry toward greater automation.

Prior authorization is automated under the EDI 278 transaction set, called Health Care Services Review Information. A healthcare provider, such as a hospital, can send a 278 transaction to request an authorization from a payer, such as an insurance company. However, the process is often bogged down for a number of reasons, including requests for paper documentation. The CAQH CORE rule, at the minimum, will speed the communication process.

In particular, the updated operating rule establishes maximum timeframes at key stages in the prior authorization process for both batch and real-time transactions.

First, a health plan, payer or its agent has two business days to review a prior authorization request from a provider and respond with a request for additional documentation needed to complete the request.

Second, after all requested information has been received from a provider, the health plan, payer or its agent has two business days to send a response containing a final determination.

Finally, the new guideline stipulates that a health plan, payer or its agent may choose to close out a prior authorization request if the additional information needed to make a final determination is not received from the provider within 15 business days of communicating specifically what additional information is needed.

The updated rule, coupled with the release of the CAQH CORE 278 Prior Authorization Data Content Rule last May, enhance the information sent in the HIPAA-mandated standard electronic transaction and enable faster responses, the organization contends.

“These industry-led efforts will benefit all stakeholders, and patients in particular,” says Tim Kaja, COO of UnitedHealthcare Networks and CAQH CORE vice chair. “In 2020, CAQH CORE Participants will continue working to improve the prior authorization process with a focus on how operating rules can streamline the exchange of medical documentation and support the use of new technologies with existing standards.”

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