CMS Releases Final Interoperability and Electronic Prior Authorization Regulation | Heart Rhythm Society

CMS Releases Final Interoperability and Electronic Prior Authorization Regulation

On January 17th, the Centers for Medicare & Medicaid Services (CMS) released its Advancing Interoperability and Improving Prior Authorization Processes final rule, which aims to improve the electronic exchange of healthcare data and streamline processes related to prior authorization through new requirements for Medicare Advantage (MA) organizations, state Medicaid fee-for-service (FFS) programs, state Children’s Health Insurance Program (CHIP) FFS programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs).

Regulatory Updates

Specifically, the rule requires impacted payers to implement standards-based application programming interfaces (APIs) to facilitate electronic sharing of health data among patients, providers, and payers  to support care continuity, and improve prior authorization communications and processes. Payers impacted by the rule are required to send prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests, to provide a specific reason for denied prior authorization decisions, and to publicly report aggregated prior authorization metrics on an annual basis (e.g., percent of requests approved/denied and average time from request to determination).

To encourage providers to adopt electronic prior authorization processes, the final rule also adds a new Electronic Prior Authorization measure for hospitals to report under the Medicare Promoting Interoperability Program and for eligible clinicians to report under the Promoting Interoperability performance category of the Merit-Based Incentive Payment System (MIPS). Insurance plans must comply with the API requirements and providers must begin reporting the Promoting Interoperability measures starting in 2027, which represents a one-year implementation delay from CMS's original proposal. However, payers must comply with other prior authorization policies—including decision timeframes, communication requirements, and public reporting of metrics— by 2026.

CMS believes the provisions in the rule will reduce overall payer and provider burden and improve patient access to health information while increasing interoperability in the health care market. The agency estimates that these policies will result in total cost savings for providers of at least $16 billion over 10 years.

The regulation was praised by the Congressional champions of the Improving Seniors' Timely Access to Care Act, who stated that the regulation will "make a big difference in helping seniors access the medical care they are entitled to without unnecessary delays and denials." Rep. Suzan DelBene (D-Wash.) explained that although the rule addresses many of the things that were in the bill, there are areas where CMS "could have gone further, especially in terms of speed of decision-making." Rep. DelBene and the other bill sponsors plan to review the final rule and "see what else we can do legislatively to not only solidify and codify what is in the rule, but also look at what we can do to try to increase speed of responses."  More information about these new requirements can be found in the CMS fact sheet.


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