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

Recording of a 90-minute CLE video webinar with Q&A

This program is included with the Strafford CLE Pass. Click for more information.
This program is included with the Strafford All-Access Pass. Click for more information.

Conducted on Tuesday, April 2, 2024

Recorded event now available

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This CLE webinar will guide counsel on the final Centers for Medicare & Medicaid Services (CMS) interoperability and prior authorization rule. The panel will discuss impacted parties, required updates to and implementation of application program interfaces (APIs), and new requirements to the prior authorization process. The panel will also address important timelines and provide best practices for compliance.


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.



  1. Introduction
  2. Updates to and implementation of APIs
  3. New requirements for prior authorization processes
  4. Compliance timeframe
  5. Notable exclusions
  6. Best practices for compliance


The panel will review these and other key considerations:

  • How will the new rule affect healthcare providers, payers, and patients?
  • What are the new timelines of which counsel and their clients should be aware?
  • Why should impacted parties begin preparing for compliance now?
  • What exceptions/exemptions are offered in the new rule?


Leiter, Alice
Alice B. Leiter

Manatt, Phelps & Phillips

Ms. Leiter focuses on health information privacy, new data use cases, data policy and health regulatory issues. She...  |  Read More

Lucas, Alexandra M.
Alexandra M. (Alex) Lucas

Reed Smith

Ms. Lucas has broad experience in healthcare compliance and regulatory issues. She frequently advises health plans...  |  Read More

Moundas, Christine
Christine Moundas

Ropes & Gray

Ms. Moundas is co-head of the firm's digital health initiative and actively participates in the data, privacy...  |  Read More

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