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PRESS RELEASES

CMS FINALIZES RULE TO EXPAND ACCESS TO HEALTH INFORMATION AND IMPROVE THE PRIOR
AUTHORIZATION PROCESS



Jan 17, 2024
 * Billing & payments
 * Medicaid & CHIP
 * Medicare Part D

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Final rule modernizes the health care system and reduces patient and provider
burden by streamlining the prior authorization process 

 

As part of the Biden-Harris Administration’s ongoing commitment to increasing
health data exchange and strengthening access to care, the Centers for Medicare
& Medicaid Services (CMS) finalized the CMS Interoperability and Prior
Authorization Final Rule (CMS-0057-F) today. The rule sets requirements for
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), (collectively “impacted
payers”), to improve the electronic exchange of health information and prior
authorization processes for medical items and services. Together, these policies
will improve prior authorization processes and reduce burden on patients,
providers, and payers, resulting in approximately $15 billion of estimated
savings over ten years.

“When a doctor says a patient needs a procedure, it is essential that it happens
in a timely manner,” said HHS Secretary Xavier Becerra. “Too many Americans are
left in limbo, waiting for approval from their insurance company. Today the
Biden-Harris Administration is announcing strong action that will shorten these
wait times by streamlining and better digitizing the approval process.” 

“CMS is committed to breaking down barriers in the health care system to make it
easier for doctors and nurses to provide the care that people need to stay
healthy,” said CMS Administrator Chiquita Brooks-LaSure. “Increasing efficiency
and enabling health care data to flow freely and securely between patients,
providers, and payers and streamlining prior authorization processes supports
better health outcomes and a better health care experience for all.”

While prior authorization can help ensure medical care is necessary and
appropriate, it can sometimes be an obstacle to necessary patient care when
providers must navigate complex and widely varying payer requirements or face
long waits for prior authorization decisions. This final rule establishes
requirements for certain payers to 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) will be required
to 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. For some payers, this new timeframe for
standard requests cuts current decision timeframes in half. The rule also
requires all impacted payers to include a specific reason for denying a prior
authorization request, which will help facilitate resubmission of the request or
an appeal when needed. Finally, impacted payers will be required to publicly
report prior authorization metrics, similar to the metrics Medicare FFS already
makes available. 

The rule also requires impacted payers to implement a Health Level 7 (HL7®) Fast
Healthcare Interoperability Resources (FHIR®) Prior Authorization application
programming interface (API), which can be used to facilitate a more efficient
electronic prior authorization process between providers and payers by
automating the end-to-end prior authorization process. Medicare FFS has already
implemented an electronic prior authorization API, demonstrating the
efficiencies other payers could realize by implementing such an API. Together,
these new requirements for the prior authorization process will reduce
administrative burden on the healthcare workforce, empower clinicians to spend
more time providing direct care to their patients, and prevent avoidable delays
in care for patients. 

In response to feedback received on multiple rules and extensive stakeholder
outreach HHS will be announcing the use of enforcement discretion for the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) X12 278 prior
authorization transaction standard to further promote efficiency in the prior
authorization process. Covered entities that implement an all-FHIR-based Prior
Authorization API pursuant to the CMS Interoperability and Prior Authorization
Final Rule (CMS-0057-F) who do not use the X12 278 standard as part of their API
implementation will not be enforced against under HIPAA Administrative
Simplification, thus allowing limited flexibility for covered entities to use a
FHIR-only or FHIR and X12 combination API to meet the requirements of the CMS
Interoperability and Prior Authorization final rule. Covered entities may also
choose to make available an X12-only prior authorization transaction. HHS will
continue to evaluate the HIPAA prior authorization transaction standards for
future rulemaking.

CMS is also finalizing API requirements to increase health data exchange and
foster a more efficient health care system for all. CMS values public input and
considered the comments submitted by the public, including patients, providers,
and payers, in finalizing the rule. Informed by these public comments, CMS is
delaying the dates for compliance with the API policies from generally January
1, 2026, to January 1, 2027. In addition to the Prior Authorization API,
beginning January 2027, impacted payers will be required to expand their current
Patient Access API to include information about prior authorizations and to
implement a Provider Access API that providers can use to retrieve their
patients’ claims, encounter, clinical, and prior authorization data. Also
informed by public comments on previous payer-to-payer data exchange policies,
we are requiring impacted payers to exchange, with a patient’s permission, most
of those same data using a Payer-to-Payer FHIR API when a patient moves between
payers or has multiple concurrent payers. 

Finally, the rule also adds a new Electronic Prior Authorization measure for
eligible clinicians under the Merit-based Incentive Payment System (MIPS)
Promoting Interoperability performance category and eligible hospitals and
critical access hospitals (CAHs) in the Medicare Promoting Interoperability
Program to report their use of payers’ Prior Authorization APIs to submit an
electronic prior authorization request. Together, these policies will help to
create a more efficient prior authorization process and support better access to
health information and timely, high-quality care.

The final rule is available to review
here: https://www.federalregister.gov/public-inspection/2024-00895/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-advancing-interoperability.

The fact sheet for this final rule is available
here: https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f.

###

 

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