In Advancing Interoperability and Improving Prior Authorization Processes final rule (CMS-0057-F), there is a requirement about processing speed for a Prior Authorization request based upon whether the request was 'expedited' or 'standard'. I do not see any mention of 'expedited' in the TR3. What needs to be done in a 278 to indicate that a request is 'expedited' to meet what is required in this final rule so that the payer can know and properly process it within the mandated timeframe?
A doctor wants to get a Prior Authorization request processed sooner than average so that their patient could have a procedure scheduled sooner. The provider wants to mark the request as 'expedited' so the payer will have to respond within 72 hours.
The UM06 is the appropriate data element for the requester to report the “level of service” when not considered to be routine. In the current 005010A1 version there are three options: 03: Emergency, E: Elective and U: Urgent. The next version will also include ME: Medicare Expedited.
The UM06 is not intended to report an expected “turn-around time’. In addition, per CMS fact sheet (Jan 17, 2024 URL: CMS Interoperability and Prior Authorization Final Rule CMS-0057-F | CMS ), they have identified ‘expedited’ as being equivalent to ‘urgent’.
Related RFIs: RFI # 2642: How do you flag turnaround time in the 278