CMS Releases Landmark Healthcare Reforms: Finalizes Rules for Enhanced Interoperability and Streamlined Prior Authorization

The Center for Medicare and Medicaid Services (CMS) has taken a step towards improving healthcare by introducing regulations that focus on interoperability and simplifying the authorization process. The finalized rule, called “CMS Interoperability and Prior Authorization ” aims to improve access to health information for both patients and providers.

This rule highlights CMS’s commitment to creating a healthcare system. One important aspect of this effort is the implementation of the Patient Access Application Programming Interface (API). Through this API patients will have the ability to access their health records, including claims, cost-sharing information, encounter data, and specific clinical details. Additionally, patients will also be able to view authorization requests and decisions using the Patient Access API.

Moreover, the rule requires affected payers to establish a Provider Access API that allows healthcare providers within their network to access information. While the initial proposal included sharing data on the quantity of items or services requiring authorization CMS made adjustments based on feedback from stakeholders. The final rule emphasizes giving patients an option to opt out and providing resources in language that’s easy to understand.

CMS mandates the use and maintenance of a payer-to-payer API that follows the Fast Healthcare Interoperability Resources (FHIR) standard. This API enables data transfer over five years, to ensure care.

The Final Rule issued by the Center for Medicare and Medicaid Services (CMS), allows organizations to implement a Prior Authorization API based on Fast Healthcare Interoperability Resources (FHIR) while still complying with HIPAA Administrative Simplification requirements.

CMS has established timeframes for making authorization decisions. Unless exempted payers must now provide decisions within 72 hours for requests and within seven calendar days for requests. This reduction in processing time aims to expedite the authorization process. The deadline for implementation is January 1, 2026.

The finalized rule emphasizes the importance of providing a reason when denying an authorization request. This requirement applies to all payers. Aims to improve communication between healthcare providers and payers. Compliance with this requirement is mandatory by January 1, 2026.

In addition, payers who are affected by this rule now must disclose authorization metrics as part of efforts to increase transparency in the healthcare system. These metrics include percentages of approvals and denials, timeframes involved in decision-making processes, and other key indicators. The initial set of metrics must be reported by March 31, 2026.

To promote progress in authorizations eligible healthcare providers under MIPS (Merit-based Incentive Payment System) as eligible hospitals and critical access hospitals must now electronically report the number of prior authorizations they handle. This step aims to enhance care coordination and needs to be confirmed by January 1, 2027.

Overall this approved regulation from CMS represents progress, toward creating a streamlined healthcare system. The suggested actions are expected to improve the efficiency of healthcare processes and help the healthcare industry adapt to a changing environment. Healthcare organizations that are affected by these changes are encouraged to embrace them to remain competitive during this time of healthcare reform.

For detailed information please refer to https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f

 

 


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