Summary
Makes four recommendations addressing the use of artificial intelligence and other automated tools in Medicaid prior authorization. Recommends that CMS clarify requirements for qualified individual review of adverse medical-necessity decisions, establish comparable safeguards in fee-for-service Medicaid, use existing oversight mechanisms to monitor managed care plans’ use of automation, and encourage state reporting and disclosure requirements.
Healthcare Implications
Provides a federal policy framework for human review, individualized medical-necessity decisions, transparency, testing, and oversight when Medicaid agencies and managed care plans use automated tools in prior authorization. The recommendations are nonbinding but may inform future CMS guidance, federal rulemaking, state Medicaid contracts, and payer governance practices.