MACPAC calls for increased transparency on AI-supported prior authorization

The Medicaid and CHIP Payment and Access Commission approved recommendations it will issue to Congress in its June report on oversight and increased transparency of artificial intelligence usage for prior authorization. The commission recommended that the Centers for Medicare & Medicaid Services clarify federal requirements that, for determinations of medical necessity, all adverse determinations, such as denials or reductions in requested services, must be reviewed and authorized by an individual with appropriate expertise and may not be made by automation tools alone. It also recommended CMS amend fee-for-service regulations to establish similar requirements and issue guidance on oversight of managed care use of automation, and that states require Medicaid health plans to disclose their use of automation, including testing, evaluation and oversight.