Decision times, denial reasons and metrics

Faster answers, and a reason

Not every part of the rule is an A P I. Some of it is about how fast payers must answer, whether they must explain a denial, and what they must publish. These process rules came into effect before the A P Is.

Time limits and a reason

Impacted payers, other than marketplace issuers on the federal exchanges, must send prior authorization decisions within seventy two hours for expedited, or urgent, requests, and within seven calendar days for standard requests. And when a request is denied, the payer must give a specific reason, whatever method it used to send the decision. As with the rest of the rule, this does not apply to drugs.

• 72 hours · urgent requests · expedited decisions · bolt
• 7 days · standard requests · calendar days · calendar
• 1 reason · for every denial · a specific reason · text

Reasons help the next step

The fact sheet explains the purpose of the denial reason. It improves communication and transparency between payers, providers and patients, and it helps a provider to resubmit the request if needed. The decision can still arrive by portal, fax, email, mail or phone, and existing notice rules are unchanged. Payers must also publicly post certain prior authorization metrics every year.

• Point 1 · A specific reason · For every denial. · text
• Point 2 · Any channel · Portal, fax, email, mail or phone. · share
• Point 3 · Resubmit · The reason shows what to fix. · pencil
• Point 4 · Public metrics · Posted on the payer's website. · chart

Check yourself

Pause and think. When a prior authorization is denied, what must the payer provide? The answer: a specific reason.

• A specific reason
• A free appointment
• A refund
• A new insurance card

Keep these in mind

Urgent decisions take seventy two hours, and standard ones seven calendar days. Every denial needs a specific reason. The rules do not cover drugs. And payers post prior authorization metrics each year.

• Urgent decisions: 72 hours; standard: seven calendar days
• Every denial needs a specific reason
• The rules do not cover drugs
• Payers post prior authorization metrics each year