LUGPA Policy Update:
CMS Releases New Interoperability and
Prior Authorization Final Rule (CMS-0057-F)

On January 17, 2024 the Centers for Medicare & Medicaid Services (CMS) announced the finalization of the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). This rule is designed to advance the electronic exchange of health information and streamline prior authorization processes for medical items and services across diverse healthcare programs.

Key Provisions:

1) Scope of Impact:
  • Applies to Medicare Advantage organizations, Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plans (QHPs) issuers on Federally-Facilitated Exchanges (FFEs).
  • Collectively referred to as "impacted payers."

2) Prior Authorization Process Improvements:
  • Establishes time limits for prior authorization decisions: 72 hours for urgent requests and seven calendar days for standard requests.
  • Requires impacted payers to provide specific reasons for denial, promoting transparency.
3) HL7 FHIR Prior Authorization API:
  • Mandates impacted payers to implement an HL7 FHIR Prior Authorization API (Application Programming Interface).
  • It aims to automate the end-to-end prior authorization process, enhancing efficiency and collaboration.
4) Expanded API Requirements:
  • Impacted payers must expand Patient Access API to include prior authorization information.
  • Introduces a Provider Access API for providers to retrieve patients' claims, encounters, clinical, and prior authorization data.
5) Payer-to-Payer FHIR API:
  • Allows the exchange of patient data between payers with patient consent, facilitating transitions or concurrent coverage.
6) MIPS and Promoting Interoperability:
  • Adds an Electronic Prior Authorization measure for eligible clinicians under MIPS.
  • Requires eligible hospitals and critical access hospitals to report their use of payers' Prior Authorization APIs.

Implementation Timeline:

  • The primary implementation is set for 2026.

Additional Resources:

LUGPA members are encouraged to review the finalized CMS Interoperability and Prior Authorization Final Rule, recognizing its impact on prior authorization processes. This rule signifies a significant advancement in electronic health information exchange, fostering a smoother end-to-end prior authorization process. LUGPA will continue to follow the rule's progress and any additional guidance from CMS.