– CAQH CORE participating organizations–consisting of healthcare providers, health plans, vendors, government entities, associations and standard-setting organizations–have come together to pass a national two-day time limit for plans to request additional info and make final decisions on prior authorization requests.
– Prior authorizations are the most costly, time-consuming administrative transaction for providers. And when the process takes too long, it can delay patient care.
– Over 80 percent of industry stakeholders agree to time limits on requests for supporting information and final determinations on prior authorizations.
CAQH CORE, a multi-stakeholder organization representing a broad spectrum of health plans, providers, vendors, and government entities, has voted to set two-day time limits on how quickly health plans must request additional supporting information from providers and make final determinations on prior authorization requests.
With this operating rule, CAQH CORE participating organizations agreed 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.
Establishes Maximum Timeframes at Key Stages in the Prior Authorization 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:
Two-Day Additional Information Request: A health plan, payer or its agent has two business days to review a prior authorization request from a provider and respond with the additional documentation needed to complete the request.
Two-Day Final Determination: Once 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.
Optional Close-Out: 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 what additional information is needed.
Why It Matters
Prior authorizations are the most costly, time-consuming administrative transaction for providers. And when the process takes too long, it can delay patient care.
Under this operating rule, the timeframe requirements must be met 90 percent of the time in a calendar month. This updated rule, coupled with the release of the CAQH CORE 278 Prior Authorization Data Content Rule in May 2019, enhances the information sent in the HIPAA-mandated standard electronic transaction and allow for faster responses. CORE Certification is now available for entities to demonstrate conformance with the CAQH CORE Prior Authorization Operating Rules and show commitment to greater prior authorization automation.
“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 Dr. Susan Turney, CEO of Marshfield Clinic Health System and CAQH CORE Board Chair. “With today’s announcement, the industry has reached a compromise to ensure they are done efficiently.”