CMS Advancing Interoperability and Improving Prior Authorization Processes Final Rule (CMS-0057-F)

In early 2024, CMS published a new rule called “CMS Interoperability and Patient Access final rule (85 FR 25510)” calling on payers to comply with API policies that will improve patient, provider, and payer access to interoperable patient data and reduce the burden of prior authorization processes.

Key features of the Interoperability and Patient Access final rule included:

• Patient Access API: By January 1, 2027, payers must add information about prior authorizations (excluding those for drugs) to the data available via that Patient Access API for the purpose of giving patients access to more of their data, and helping patients understand their payer’s prior authorization process and its impact on their care.
• Provider Access API: By January 1, 2027, payers must implement and maintain a Provider Access API to share patient data with in-network providers with whom the patient has a treatment relationship
• Payer-to-Payer API: By January 1, 2027, make available claims and encounter data, data classes and data elements in the USCDI and information about prior authorizations (excluding those for drugs) – all to help improve care continuity when a patient changes payers and ensure that patients have continued access to the most relevant data in their records.
• Prior Authorization API: By January 1, 2027, payers must implement and maintain a Prior Authorization API that is populated with its list of covered items and services, can identify documentation requirements for prior authorization approval, and supports a prior authorization request and response.

In addition, the Final Rule created guidelines to Improve Prior Authorization Processes, requiring payers to follow new Prior Authorization rules by January 1, 2026, including:

• Send prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests
• Provide a specific reason for denied prior authorization decisions, regardless of the method used to send the prior authorization request
• To publicly report certain prior authorization metrics annually by posting them on their website

Get more details on the Final Rule from CMS or view the rule in the Federal Register.

CMS Interoperability and Prior Authorization Final Rule CMS-0057-F | CMS. (2024, June 4). https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f

News Coverage

Marselas, K. (2023, December 1). Medicare Advantage plans intent on skirting new rules, providers fear. McKnight’s Long-Term Care News. https://www.mcknights.com/news/medicare-advantage-plans-intent-on-skirting-new-rules-providers-fear/

Herman, B. (2024, February 5). Let the Medicare Advantage lobbying begin. STAT. https://www.statnews.com/2024/02/05/medicare-advantage-lobbying/

Ross, C., & Herman, B. (2024, February 7). Government warns Medicare Advantage insurers not to deny care based on AI. STAT. https://www.statnews.com/2024/02/07/government-warns-medicare-advantage-insurers-not-to-deny-care-based-on-ai/

Henreckson, J. (2024, Jan 12). CMS pledges to use ‘full array’ of tools to enforce 2024 Medicare Advantage rules – McKnight’s Long-Term Care News. McKnight’s Long-Term Care News. https://www.mcknights.com/news/cms-pledges-to-use-full-array-of-tools-to-enforce-2024-medicare-advantage-rules/

Biden-Harris administration launches effort to increase Medicare advantage Transparency | CMS. (2024, January 25). https://www.cms.gov/newsroom/press-releases/biden-harris-administration-launches-effort-increase-medicare-advantage-transparency

Henreckson, J. (2024, Jan 18). CMS finalizes long-awaited prior authorization rule for Medicare Advantage – McKnight’s Long-Term Care News. McKnight’s Long-Term Care News. https://www.mcknights.com/news/cms-finalizes-long-awaited-prior-authorization-rule-for-medicare-advantage/