CMS sent FAQs to the Medicare Advantage Plans (MAPs) back in February regarding coverage criteria and utilization management requirements included in Final Rule CMS-4201-F. It’s all good stuff, but one of the questions addresses the very unpopular MAP practice of not honoring their own prior authorization decisions.

Next Episode: Thursday, June 20, 2024

Can MAPs use post-claim audits to deny payment of a prior authorized service? In response to this question posed in FAQ #9, CMS wrote:
“If a MAP approved the furnishing of a covered item or service through a prior authorization … it may not deny coverage later on the basis of lack of medical necessity and may not reopen such a decision for any reason except for good cause … or if there is reliable evidence of fraud or similar fault.”
CMS has raised the bar pretty high for MAPs to walk back its own prior authorization decisions. Good cause requires new and material evidence that:
  1. Would result in a different conclusion, and
  2. Was not available to or known by the MAP at the time of the prior authorization decision.
We expect CMS’s clarity will significantly reduce what has been a longstanding supplier frustration in working with Medicare Advantage Plans.