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CMS final rule reforms prior authorization in Medicare Advantage plans

Posted On: Apr. 6, 2023 10:10 AM CST

A new final rule by the Centers for Medicare & Medicaid Services sets new prior authorization requirements for Medicare Advantage plans, Fierce Healthcare reports. One of the key changes applies to the prior authorization tool insurers use to require providers to get approval before offering a certain service or drug. The rule includes new continuity of care requirements that says coordinated care plans can only use prior authorization “to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary,” according to a fact sheet.