Prior Authorization

CAQH CORE: Building Momentum for End-to-End Automation of the Prior Authorization Process 

Prior authorization (PA) began as a way to manage the utilization of healthcare resources. It requires providers to request approval from a health plan before a specific procedure, service, medication or device is provided to the patient. Each step of the process generates administrative burden and can delay patient care.​

Numerous barriers have prevented or slowed the adoption of electronic prior authorization. These barriers are wide-ranging, encompassing the nature of the transaction itself, the lack of operating rules to support use of the electronic transaction standard, a lack of infrastructure supporting electronic submission of supporting clinical documentation, vendor readiness, the ubiquity of web portals and a myriad of state laws. In addition, some components of the prior authorization workflow occur outside the scope of the electronic standard. Recently, a groundswell of momentum to reduce the prior authorization administrative burden has sparked innovative collaborations, state laws and broad policy discussions to help the industry move toward more efficient prior authorization processes.

EXISTING CAQH CORE PRIOR AUTHORIZATION OPERATING RULES

As a result of a prioritized effort by over 100 CAQH CORE Participating Organizations, the Phase V CAQH CORE Operating Rules for prior authorization were released in May 2019. These rules include the Prior Authorization (278) Request / Response Data Content Rule and the Prior Authorization Web Portal Rule. Together with the Phase IV CAQH CORE Prior Authorization Infrastructure Rule, these operating rule requirements reduce the unnecessary back and forth between providers and health plans, accelerate adjudication timeframes and reduce provider resources spent on manual follow up.

CONTINUED EFFORTS TO MINIMIZE PRIOR AUTHORIZATION BURDEN AND INCREASE AUTOMATION

As part of its integrated model, CAQH CORE continually measures the impact of operating rules, including maintenance and updates to meet evolving industry business needs. For example, CAQH CORE Participating Organizations are currently evaluating an update to requirements in the Phase IV Prior Authorization Rule. The updates under consideration focus on establishing maximum timeframes at key stages in the prior authorization process, including a timeframe for final determination. This rule would set national expectations around a final response to a prior authorization request and will enable more timely delivery of patient care. ​

In addition, CAQH CORE is collaborating with standards development organizations focusing on the interplay of existing and emerging standards and operating rules to close automation gaps and streamline the prior authorization process. The Prior Authorization Pilot Initiative allows industry organizations to partner with CAQH CORE to measure the impact of existing and new prior authorization operating rules and corresponding standards on organizations’ efficiency metrics. This initiative ensures that prior authorization operating rules support industry organizations in varying stages of maturity along the standards and technology adoption curve. Pilots also allow for identification of new operating rules to support greater automation of the end-to-end prior authorization workflow.

For more information on how to get involved with the CAQH CORE Prior Authorization Initiatives,email core@caqh.org.

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