MHCC recommends prior‑authorization data reporting, EHR API adoption and continued monitoring

The Maryland Health Care Commission on Jan. 23 briefed the Senate Finance Committee on the study of health insurance prior authorization and proposed three recommendations to streamline electronic prior authorization and improve transparency.

MHCC staff said the recommendations respond to implementation realities and federal action. “The Centers for Medicare and Medicaid Services released … an interoperability and prior authorization final rule” on Jan. 17, 2024, MHCC noted, and Maryland should align state policy to reduce administrative burden and bring prior authorization into electronic health record workflows.

MHCC’s three recommendations for the legislature are: (1) require commercial payers to include an indicator on claims when a service required prior authorization and submit that indicator to MHCC’s All‑Payer Claims Database beginning in 2026 to allow measurement of utilization impacts; (2) require EHR vendors to implement the electronic prior authorization API in accordance with the CMS interoperability and prior authorization final rule and encourage payers to use the CMS API implementation guide; and (3) monitor the implementation and impact of the 2024 law on providers and commercial payers and submit an annual report to the legislature through 2028.

The commission told senators that reporting prior‑authorization metrics increases transparency and makes it possible to measure effects on spending, specialist access and consumer experience. MHCC staff said the CMS rule requires payers to issue decisions on non‑urgent prior authorizations within seven calendar days and expedited requests within 72 hours, and that aligning state expectations with federal interoperability standards would allow providers to identify prior‑authorization requirements, retrieve necessary patient data and exchange requests/responses from within EHR workflows.

MHCC recommended that the legislature adopt the report’s proposals to reduce the administrative burden on clinicians and encourage adoption of standards that support real‑time benefit tools and gold‑carding programs where appropriate. No committee votes were taken during the briefing; MHCC said it will continue work with stakeholders and produce status updates as it and the Maryland Insurance Administration (MIA) monitor compliance.

The report and recommended next steps are intended to move prior authorization toward standardized electronic exchange and measurable reporting so policymakers can evaluate whether the reforms reduce delays in care and lower administrative costs.