The Centers for Medicare & Medicaid Services (CMS) has recently finalized a rule addressing interoperability and improving prior authorization processes with the publication of the CMS Interoperability and Prior Authorization final rule (CMS-0057-F). This rule, which impacts Medicare Advantage plans, state Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan Issuers on the Federally Facilitated Exchanges (FFEs), introduces key measures to streamline electronic health data exchange and enhance patient and provider access.
Key aspects of the rule encompass establishing clear timeframes for responding to prior authorization requests, providing explicit reasons for denials, and mandating the public disclosure of metrics concerning both approvals and denials. Additionally, the rule compels payers to develop and sustain a system facilitating the automation of processes for providers. This system aids in determining the necessity for prior authorization, identifying required documentation, and expediting requests and decisions. While several Application Programming Interfaces (API) related requirements become effective on January 1, 2027, changes to the prior authorization process, such as decision timeframes, will be operational starting January 1, 2026. The inaugural set of metrics must be reported by March 31, 2026. Read ANCOR’s comments on the proposed rule.