Last month, CMS published its Interoperability and Prior Authorization final rule, which applies to Medicare Advantage organizations, state Medicaid and Children's Health Insurance Program plans, Medicaid managed care plans, CHIP managed care entities and Qualified Health Plan issuers.
Under the rule, the programs and groups are required to implement and maintain certain Health Level 7 Fast Healthcare Interoperability Resources application programming interfaces for the purpose of improving the electronic exchange of healthcare data and streamlining the prior authorization process, according to a Feb. 7 blog post from Coronis Health.
The final rule also adds a new measure for merit-based incentive payment system-eligible clinicians to improve patient data collection and reduce prior authorization-related burdens.
Impacted payers have to implement certain operational provisions beginning Jan. 1, 2026, but generally have until Jan. 1, 2027, to implement its advanced requirements.
Payers are required to add information about prior authorizations to their patient access API by 2027.
Payers must also implement and maintain a provider access API to share patient data, such as claims and prior authorization info, with in-network providers by 2027.
Under the rule, payers have to communicate if and why a prior authorization request is denied. Impacted payers must send prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests beginning in 2026.