Electronic Preauthorization
Federal and state policymakers are increasingly focused on reforming prior authorization to reduce administrative burdens and improve timely access to care. Recent initiatives and legislative efforts aim to streamline processes, enhance transparency, and leverage technology to make prior authorization more efficient for providers and patients.
State Law
In 2012, Maryland became one of the first states to enact legislation that required State-regulated payors and pharmacy benefits managers (PBMs) to implement an electronic prior authorization process. Md. Code Ann., Health-General Article § 19-108.2 required the MHCC to work with payors and PBMs to:
- provide online access to all medical services and pharmaceuticals requiring preauthorization, along with the key criteria for determinations (2012);
- establish an online system to receive electronic prior authorization requests and assign a unique tracking number to each request (2013);
- process electronic requests for pharmaceuticals in real-time or within one business day and non-urgent medical services within two business days (2013); and
- implement an electronic override process for step therapy or fail-first protocols for pharmaceutical prior authorizations (2015).
Waiver Requests
COMAR 10.25.17.05 established a process by which a payor may be waived from attaining one or more requirements. All initial waiver requests or requests to renew a waiver should be submitted to Justine Springer at justine.springer@maryland.gov.
Payor and PBM Online Portals
State-Mandated Online Process
During the 2024 legislative session, the Maryland General Assembly passed Chapter 848 (Senate Bill 791) and Chapter 847 (House Bill 932), Health Insurance – Utilization Review – Revisions, which requires payors and PBMs to implement an online process for pharmaceuticals that meets the following requirements:
- Link directly to all e-prescribing and electronic health record (EHR) systems that use the National Council for Prescription Drug Programs (NCPDP) SCRIPT standard and the NCPDP Real Time Benefit Standard;
- Accept electronic prior authorization requests from a healthcare provider;
- Approve prior authorization requests for which no additional information is required by the payor to process the electronic prior authorization request, for which no clinical review is required, and that meet the payor’s criteria for approval; and
- Link directly to real-time patient out-of-pocket costs, including copayment, deductible, and coinsurance costs, and more affordable medication alternatives at the point of prescribing.
The law also directed the MHCC and the Maryland Insurance Administration (MIA) to conduct studies and submit the following reports to the Maryland General Assembly. To access the 2024 and 2025 reports, visit Archived Reports.
Contact Us
For more information, please email Justine Springer at justine.springer@maryland.gov.