On January 17, 2024, CMS released the Interoperability and Prior Authorization Final Rule (CMS-0057-F) setting requirements for certain payor types impacting long-term care providers, including Medicare Advantage organizations and Medicaid-managed care plans among other types of payors. The intention of this final rule is to ease the exchange of electronic health records (EHR) and improve medical prior authorization processes.
Prior Authorization
Starting in 2026, the final rule aims to shorten waiting time for patients with prior authorization requests for medical care and services by implementing three main requirements payors must adhere to during the prior authorization process:
- Prior authorization decisions for expedited requests must be communicated within 72 hours and within seven calendar days for normal requests.
- When denying a prior authorization request, the payor must provide a specific reason to make it easier for patients to resubmit the request or file an appeal.
- Payors must publicly report global prior authorization decision statistics such as the total number of prior authorization requests, timeliness of communication decisions, accuracy, and appeals data.
EHR Exchange
The goal of the EHR requirements is to simplify and secure EHR data exchange among different patient providers, which will also ease the prior authorization process through automation software. Beginning January 1, 2027, the final rule mandates implementation of Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) application programming interfaces (APIs). APIs are software programs that act as a go-between to allow different software applications to communicate with each other.
Additional API requirements are being finalized by CMS, including expanding API access to include prior authorization decisions as well as access to patient claims and clinical data. With patient permission, payors will also be required to exchange this information when a patient changes payors or has several different payors.
If you have any questions or need assistance, please reach out to a healthcare industry professional at Forvis Mazars.