Ama Policy

Prior Authorization Relief in Medicare Advantage Plans H-320.938

Amendments, Retroactive Denial

Our AMA supports legislation and/or regulations that would apply the following processes and parameters to prior authorization (PA) for Medicaid and Medicaid managed care plans and Medicare Advantage plans:

a. List services and prescription medications that require a PA on a website and ensure that patient informational materials include full disclosure of any PA requirements.

b. Notify providers of any changes to PA requirements at least 45 days prior to change.

c. Improve transparency by requiring plans to report on the scope of PA practices, including the list of services and prescription medications subject to PA and corresponding denial, delay, and approval rates.

d. Standardize a PA request form.

e. Minimize PA requirements as much as possible within each plan and eliminate the application of PA to services and prescription medications that are routinely approved.

f. Pay for services and prescription medications for which PA has been approved unless fraudulently obtained.

g. Allow continuation of medications already being administered or prescribed when a patient changes health plans, and only change such medications with the approval of the ordering physician.

h. Make an easily accessible and responsive direct communication tool available to resolve disagreements between health plan and ordering provider.

i. Define a consistent process for appeals and grievances, including to Medicaid and Medicaid managed care plans.

Policy Timeline

Res. 814, I-18 Reaffirmation: A-22