Preproposal Statement of Inquiry: Prior Authorization Modernization and Substance Use Disorder Treatment
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This document is a preproposal statement of inquiry about updating prior authorization rules and substance use disorder treatment authorization for commercial plans regulated by the agency.
Planned prior authorization updates
Planned Scope of Coverage Changes
Planned scope of coverage-related rule changes
Planned rulemaking may include the following updates affecting coverage and utilization management:
ALL of the following
Potential updates
- Updating prior authorization review timeframes
- Updating clinical review criteria
- Updating prior authorization processes
- Updating initial authorization requirements for substance use disorder treatment
- Clarifying considerations for medical necessity determinations for substance use disorder treatment
Planned Prior Authorization Updates and Provider Impacts
Planned updates to prior authorization review timeframes, criteria, and processes
The agency plans to update prior authorization processes by revising review timeframes, clarifying clinical review criteria, and amending authorization procedures. Providers should expect changes to how and when prior authorizations are reviewed and the clinical standards used to evaluate requests.
- Update prior authorization review timeframes.
- Revise clinical review criteria used for authorizations.
- Amend prior authorization processes and procedures.
Definitions Related to Prior Authorization and SUD Treatment
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