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The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)

The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) has been finalized by the Centers for Medicare and Medicaid Services (CMS), January 17, 2024.


Why?


To expand Access to Health Information and Improve the Prior Authorization Process.


Who are the "impacted payers"?


  • Medicare Advantage (MA) organizations,

  • Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs,

  • Medicaid managed care plans,

  • CHIP managed care entities,

  • and issuers of Qualified Health Plans (QHPs) offered on the Federally Facilitated Exchanges (FFEs)


Why are these new requirements/policies of the prior authorization process?


  • They will improve the electronic exchange of health information and prior authorization processes for medical items and services, and reduce burden on patients, providers, and payers.


  • They will reduce administrative burden on the healthcare workforce, allow clinicians to spend more time providing direct care to their patients, and prevent unnecessary delays in care for patients.


What are the requirements?


  • Certain payers must streamline the prior authorization process and complements the Medicare Advantage requirements finalized in the Contract Year (CY) 2024 MA and Part D final rule, which add continuity of care requirements and reduce disruptions for beneficiaries.


  • Beginning primarily in 2026, impacted payers (not including QHP issuers on the FFEs) must send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests for medical items and services.


  • All impacted payers must include a specific reason for denying a prior authorization request, which will help facilitate resubmission of the request or appeal it when needed.


  • Impacted payers will publicly report prior authorization metrics, similar to the metrics - PDF Medicare FFS already makes available.


  • Impacted payers must also implement a Health Level 7 (HL7®) Fast Healthcare Interoperability Resources (FHIR®) Prior Authorization application programming interface (API), which will facilitate a more efficient electronic prior authorization process between providers and payers by automating the end-to-end prior authorization process.


"II. Provisions of the Proposed Rule:


A. Patient Access API

B. Provider Access API


C. Payer-to-Payer API

D. Prior Authorization API and Improving Prior Authorization Processes

E. Extensions, Exemptions, and Exceptions; Federal Matching Funds for Medicaid and CHIP CMS-0057-F 4

F. Electronic Prior Authorization Measures for the Merit-based Incentive Payment System (MIPS) Promoting Interoperability Performance Category and the Medicare Promoting Interoperability Program


G. Interoperability Standards for APIs."



The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)


Programming


To be continued...


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