Key Takeaways

• CMS clarified that prior authorization disclosures must be publicly accessible without password-protected portals and must identify all medical items and services subject to prior authorization.
• Lists consisting only of procedure codes do not satisfy transparency requirements; CMS recommends plain-language descriptions and standardized service categories.
• CMS requires turnaround-time metrics to include units of time and directs that median turnaround times of less than 1 day be reported in hours.

The Centers for Medicare & Medicaid Services (CMS) has issued updated guidance strengthening federal prior authorization transparency requirements, including new clarification on how health plans must make prior authorization policies and performance data accessible and understandable to patients and physicians.

The guidance addresses several concerns raised by the AMA after its review of 15 Medicare Advantage contracts found that required disclosures were often difficult to locate, incomplete, or presented in formats that were difficult to interpret. The review examined implementation of transparency provisions in the 2024 CMS Interoperability and Prior Authorization final rule.

CMS clarified that prior authorization information is not considered publicly accessible if it is available only through password-protected portals or cannot be reached through ordinary navigation from a payer’s public-facing website. Plans also must publicly identify all medical items and services subject to prior authorization.

The agency further stated that lists of procedure codes without plain-language descriptions do not satisfy transparency requirements. CMS recommends that payers provide a single, comprehensive list organized by uniform service categories and including CPT codes, plain-language descriptions, and a machine-readable format.

CMS also addressed data reporting. Turnaround-time metrics must include a unit of time, and median turnaround times of less than 1 day must be reported in hours rather than rounded to 0 days. CMS also recommended that payers explain data-quality issues affecting their reports.

The AMA had documented instances in which plans posted extensive lists of billing codes without plain-language explanations, placed disclosures behind physician or member portals, reported statistics that the AMA characterized as mathematically impossible, and omitted categories such as behavioral health and postacute services.

“CMS has taken an important step toward making prior authorization information more transparent and usable,” AMA President Willie Underwood III, MD, MSc, MPH, said.

The AMA is urging CMS to take additional steps, including defining prior authorization based on how the process functions regardless of terminology, linking prior authorization information to federal and state plan-comparison tools, and requiring standardized reporting templates.