CMS Final Interoperability and Prior Authorization Rule: Impacted Parties, API Implementation, Reporting Requirements

Description

The CMS recently released its final interoperability and prior authorization processes rule that will require certain payers to automate their prior authorization processes and implement APIs to improve the exchange of health information among payers, providers, and patients. Impacted payers include Medicare Advantage/Medicare Part D plans, state Medicaid and Children's Health Insurance Program (CHIP) fee-for-service programs (FFS), Medicaid managed care plans and CHIP managed care entities, and Qualified Health Plan issuers on the Federally Facilitated Exchanges (FFEs).

The new rule complements the Office of the National Coordinator for Health Information Technology's efforts to improve the access, exchange, and use of electronic health information and aims to reduce provider burden related to prior authorization processes and improve patient access to timely care.

Key provisions of the new rule include: (1) updating requirements for the previously established Patient Access API and establishing three new required APIs--Provider Access API, a Payer-to-Payer API, and a Prior Authorization API; (2) outlining new timeframes for prior authorization decisions; (3) requiring impacted payers to provide specific reasons for denials of prior authorization requests within the new timeframes; (4) creating new reporting requirements for impacted payers related to certain aggregated prior authorization metrics; (5) creating new electronic prior authorization measures for the Merit-Based Incentive Payment System and the Medicare Promoting Interoperability Program; and (6) providing certain extensions, exemptions, and exceptions to state Medicaid and CHIP FFS programs.

Listen as our expert panel guides practitioners through CMS' final interoperability and prior authorization rule and provides a compliance timeline. The panel will offer best practices for addressing the required changes and steps for complying with the new regulations.