The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), released on January 17, 2024, streamlines medical prior authorization and enhances transparency to improve efficiency, responsiveness, and patient access to care. Within the Rule, there are several core functionality requirements for health plans including:
Prior Authorization Decision Timeframes for Standard Requests
For standard (non-urgent) medical prior auth requests, impacted payers are required to provide decisions within seven calendar days from the date of submission. The decision must result in approval, denial, or are quest for additional information. If additional information is required, the seven-day clock resets upon receipt of the requested data.
Payers must publicly report PA processing times to ensure timely access to necessary medical services and reduce delays in patient care.
How Banjo Health Can Help:
Turnaround Time Manager: Banjo’s Turnaround Time Manager configures the required turnaround times to ensure that specific lines of business and plans meet the regulation.
AI-Driven Automation: Banjo Health’s AI-driven prior authorization review process significantly reduced processing times, sometimes by over 70%.
Easy-to-Read Interface: Live timers count down time remaining on the case, and change colors to highlight if time is running out. The case due date is presented in multiple places so users are always aware of the remaining period to meet the required turnaround time.
Expedited Requests Within 72 Hours
If a faster decision is clinically necessary, providers can request an expedited review. For expedited prior authorization requests, payers must provide decisions within 72 hours of receiving the request. This requirement aims to facilitate prompt medical attention in critical scenarios.
How Banjo Health Can Help:
AI-Powered Triage: The BanjoPA system classifies urgent requests and prioritizes them accordingly, helping to meet the 72-hour expedited requirement.
Interoperability: Seamless integration with EHRs, payers, and more ensures that requests contain complete and accurate data, thus reducing delays due to missing information.
Core Reporting Statistics
Beginning in 2026, impacted payers are mandated to publicly report specific prior authorization metrics on their websites. These metrics include:
- The number of prior authorization requests received.
- The number of requests approved.
- The number of requests denied.
- The number of requests approved after appeal.
- The average time taken to make prior authorization determinations.
This transparency initiative is intended to provide patients and providers with insights into payer performance and promote accountability in the prior authorization process.
How Banjo Health Can Help:
Automated Compliance Reporting: Banjo Health’s platform tracks and reports PA metrics required by CMS, including the statistics required by CMS-0057.
Real-Time Dashboards & Insights: Real-time analytics and insights help health plans monitor performance, optimize workflows, and ensure CMS compliance.
The CMS-0057 provisions collectively aim to enhance the efficiency, transparency, and responsiveness of prior authorization procedures, ultimately improving patient access to necessary healthcare services. Banjo Health assists in proving this timely access to care by automating and streamlining the PA process, helping payers and health plans prepare for the upcoming changes.
