UnitedHealthcare CMS Interoperability and Prior Authorization Final Rule

The Centers for Medicare & Medicaid Services (CMS) released the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) on Jan. 17, 2024. This final rule emphasizes the need to improve health information exchange to achieve appropriate and necessary access to health records for patients, healthcare providers and payers. This final rule also focuses on efforts to improve prior authorization processes through policies and technology, to help ensure that patients remain at the center of their own care. (This includes Medicare Advantage (MA), Medicaid and Individual & Family plans [IFP]). We are posting the CMS Interoperability Prior Authorization data based on the requirements outlined in the CMS Final Rule 2025.

UnitedHealthcare is required to provide CMS Interoperability data to publicly report aggregated prior authorization metrics, by posting MA organizations at the contract level, state Medicaid and Children's Health Insurance Program (CHIP) Fee-For-Service (FFS) programs at the state level, Medicaid managed care plans and CHIP managed care entities at the plan level, and Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs) at the issuer level using data from the prior calendar year. This includes: 

• A list of all items and services that require prior authorization
• The percentage of standard prior authorization requests that were approved, aggregated for all items and services
• The percentage of standard prior authorization requests that were denied, aggregated for all items and services
• The percentage of standard prior authorization requests that were approved after appeal, aggregated for all items and services
• The percentage of prior authorization requests for which the timeframe for review was extended, and the request was approved, aggregated for all items and services
• The percentage of expedited prior authorization requests that were approved, aggregated for all items and services
• The percentage of expedited prior authorization requests that were denied, aggregated for all items and services
• The average and median time that elapsed between the submission of a request and a determination by the payer, plan or issuer, for standard prior authorizations, aggregated for all items and services
• The average and median time that elapsed between the submission of a request and a decision by the payer, plan or issuer, for expedited prior authorizations, aggregated for all items and services

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