Ama Policy

Prior Authorization and Utilization Management Reform H-320.939

U.R. Criteria

1. Our AMA will continue its widespread prior authorization (PA) advocacy and outreach, including promotion and/or adoption of the Prior Authorization and Utilization Management Reform Principles, AMA model legislation, Prior Authorization Physician Survey and other PA research, and the AMA Prior Authorization Toolkit, which is aimed at reducing PA administrative burdens and improving patient access to care.

2. Our AMA will oppose health plan determinations on physician appeals based solely on medical coding and advocate for such decisions to be based on the direct review of a physician of the same medical specialty/subspecialty as the prescribing/ordering physician.

3. Our AMA supports efforts to track and quantify the impact of health plans’ prior authorization and utilization management processes on patient access to necessary care and patient clinical outcomes, including the extent to which these processes contribute to patient harm.

4. Our AMA will advocate for health plans to minimize the burden on patients, physicians, and medical centers when updates must be made to previously approved and/or pending prior authorization requests.

Policy Timeline

CMS Rep. 08, A-17Reaffirmation: I-17Reaffirmed: Res. 711, A-18Appended: Res. 812, I-18Reaffirmed in lieu of: Res. 713, A-19Reaffirmed: CMS Rep. 05, A-19Reaffirmed: Res. 811, I-19Reaffirmed: CMS Rep. 4, A-21Appended: CMS Rep. 5, A-21 Reaffirmation: A-22