Currentwellsense_health_planPolicy N/A

Relaxation of Prior Authorization and Credentialing Procedures

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This Bulletin directs Massachusetts commercial health insurers and HMOs to temporarily relax prior authorization and credentialing procedures to address health facility staffing and capacity constraints; it affects carriers operating in Massachusetts and entities they administer for.

Policy Summary

Payerwellsense_health_plan

PolicyRelaxation of Prior Authorization and Credentialing Procedures

Policy CodePolicy N/A

Change TypeClarified (temporary administrative relief)

Effective DateN/A

Next Review DateN/A

Key ActionForego prior authorization reviews for scheduled surgeries and inpatient admissions and ensure facilities notify carriers within 24 hours and provide updates at least every five days.

SourceLink

POLICY UPDATE CHANGES

Carriers are expected to forego prior authorization reviews for scheduled surgeries and admissions at acute care, mental health hospitals, and post-acute care facilities for 90 days following the Bulletin issuance.

Carriers should develop expedited credentialing modifications for newly credentialing or modifying practitioners for 90 days following the Bulletin issuance.

90 daystemporary relaxation period specified

24 hourscarrier notification timeframe

every 5 daysminimum update frequency

Massachusettsjurisdiction

Temporary Administrative Relief Criteria

Temporary administrative relief criteria

Operational criteria and expectations for carriers during the 90-day period:

Carriers will forego prior authorization reviews for any scheduled surgeries and behavioral health or non-behavioral health admissions at acute care hospitals, mental health hospitals, and post-acute care facilities for 90 days following the issuance date of this Bulletin.

Facilities must notify Carriers of any inpatient admissions within 24 hours of a patient being admitted for care.

Facilities must provide updates to Carriers at a minimum every five (5) days to enable Carriers to support discharge planning.

Carriers will examine and modify credentialing systems to expedite network credentialing for practitioners who are newly credentialing or seeking to modify existing credentialing materials for 90 days following the issuance of this Bulletin.

In establishing expedited credentialing policies, Carriers must continue to adhere to standards set forth by NCQA and the Massachusetts Board of Registration in Medicine and develop clear materials explaining the expedited process to practitioners.

When acting as administrators for employer-sponsored non-insured health benefit plans, Carriers should encourage plan sponsors to provide similar administrative relief for providers, hospitals, and post-acute care facilities for 90 days following the issuance of this Bulletin.

Coding and Thresholds

No coding changes specifiedmixed

No codes listed

No thresholds specified

Thresholds specifiedNone — the brief and source indicate no thresholds are specified for coding or utilization in this Bulletin.

Related coding changesNo coding changes specified (0 codes).

Effective period noted elsewhereOperational relief applies for a 90-day period (see coverage criteria).

Provider Expectations and Notification Requirements

Prior Authorization

Temporary suspension of prior authorization and admission notification expectations

Carriers are expected to forego prior authorization reviews for any scheduled surgeries and behavioral and non-behavioral health admissions at acute care hospitals, mental health hospitals, and post-acute care facilities for 90 days following the Bulletin issuance. Facilities must notify carriers of any inpatient admissions within 24 hours of admission and provide updates at least every five (5) days to enable carriers to support discharge planning.

Forego prior authorization reviews for scheduled surgeries and behavioral and non‑behavioral health admissions at acute care hospitals, mental health hospitals, and post‑acute care facilities for 90 days following the Bulletin issuance.
Notify carriers of any inpatient admission within 24 hours of the patient being admitted.
Provide updates to carriers at least every five (5) days to support discharge planning.

Key Terms and Processes

Prior authorization

DefinitionUtilization review processes, like prior authorization, used by Carriers to ensure members access appropriate care at the right time and in the right setting.

Temporary expectationCarriers are expected to forego prior authorization reviews for scheduled surgeries and behavioral and non-behavioral health admissions at acute care, mental health hospitals, and post-acute care facilities for 90 days following the Bulletin issuance.

Provider notification requirementFacilities must notify Carriers of inpatient admissions within 24 hours and provide updates at least every five (5) days to support discharge planning.

Credentialing

DefinitionCarrier processes to verify and approve providers within managed care networks (credentialing) to ensure quality care in accordance with M.G.L. c. 176O and 211 CMR 52.00.

Temporary expectationFor 90 days following the Bulletin, Carriers should examine and develop modifications to expedite network credentialing for newly credentialing practitioners or those modifying existing credentialing materials.

Standards to maintainWhile expediting, Carriers should continue to adhere to NCQA standards and the Massachusetts Board of Registration in Medicine requirements and provide clear materials explaining the expedited process to practitioners.

Policy Summary

Payerwellsense_health_plan

PolicyRelaxation of Prior Authorization and Credentialing Procedures

Policy CodePolicy N/A

Change TypeClarified (temporary administrative relief)

Effective DateN/A

Next Review DateN/A

Key ActionForego prior authorization reviews for scheduled surgeries and inpatient admissions and ensure facilities notify carriers within 24 hours and provide updates at least every five days.

SourceLink

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Relaxation of Prior Authorization and Credentialing Procedures

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Sign up for all wellsense_health_plan policy alerts

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Temporary Administrative Relief Criteria

Temporary administrative relief criteria

Operational criteria and expectations for carriers during the 90-day period:

Facilities must notify Carriers of any inpatient admissions within 24 hours of a patient being admitted for care.

Facilities must provide updates to Carriers at a minimum every five (5) days to enable Carriers to support discharge planning.

Coding and Thresholds

No coding changes specifiedmixed

No codes listed

No thresholds specified

Thresholds specifiedNone — the brief and source indicate no thresholds are specified for coding or utilization in this Bulletin.

Related coding changesNo coding changes specified (0 codes).

Effective period noted elsewhereOperational relief applies for a 90-day period (see coverage criteria).

Provider Expectations and Notification Requirements

Prior Authorization

Temporary suspension of prior authorization and admission notification expectations

Forego prior authorization reviews for scheduled surgeries and behavioral and non‑behavioral health admissions at acute care hospitals, mental health hospitals, and post‑acute care facilities for 90 days following the Bulletin issuance.
Notify carriers of any inpatient admission within 24 hours of the patient being admitted.
Provide updates to carriers at least every five (5) days to support discharge planning.

Key Terms and Processes

Prior authorization

DefinitionUtilization review processes, like prior authorization, used by Carriers to ensure members access appropriate care at the right time and in the right setting.

Provider notification requirementFacilities must notify Carriers of inpatient admissions within 24 hours and provide updates at least every five (5) days to support discharge planning.

Credentialing

DefinitionCarrier processes to verify and approve providers within managed care networks (credentialing) to ensure quality care in accordance with M.G.L. c. 176O and 211 CMR 52.00.