Knowledge Center

The Centers for Medicare & Medicaid Services (CMS) has released the Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule. With this rule, the Agency seeks to improve patient and provider access to health information and streamline processes related to prior authorization.

The rule includes proposals requiring implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization.

The following requirements for certain payers are included:

• A specific reason when denying requests.
• Publicly report certain prior authorization metrics.
• Send decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent).

CMS also proposes to add a new Electronic Prior Authorization measure for eligible hospitals and critical access hospitals under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category.

CMS also proposes expanding the current Patient Access API to include the following:

• Information about prior authorization decisions.
• Allowing providers to access their patients’ data by requiring payers to build and maintain a Provider Access FHIR API, to enable data exchange from payers to in-network providers with whom the patient has a treatment relationship.
• Creating longitudinal patient records by requiring payers to exchange patient data using a Payer-to-Payer FHIR API when a patient moves between payers or has concurrent payers.

These proposed requirements would generally apply to the following organizations:

• Medicare Advantage (MA) organizations
• State Medicaid and Children’s Health Insurance Program (CHIP) agencies
• Medicaid managed care plans
• CHIP managed care entities
• Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs), promoting alignment across coverage types.

The proposed rule also includes five requests for information related to standards and the electronic exchange of health information.

Review this fact sheet for additional information on this proposed rule. CMS will accept comments from the public on this proposed rule until March 13, 2023. WEDI will be creating programming to educate WEDI members on this CMS proposed rule and will conduct Member Position Advisory initiatives to develop our response(s) to this important regulation.