CMS Releases Rule to Streamline Prior Authorizations and Ease Exchange of Health Information

On January 15, 2021, the Centers for Medicare and Medicaid Services (CMS) released a final rule, the CMS Interoperability and Prior Authorization Rule, to streamline prior authorization and patient and provider access to medical records.

The rule requires Medicaid and Children's Health Insurance Program (CHIP) managed care plans, state Medicaid and CHIP fee-for-service programs and Qualified Health Plan payers to build application programming interfaces ("APIs") that will allow providers better access to information about their patients and ease the process of obtaining prior authorizations. These APIs are the base for smartphone applications and when combined with the patient's electronic health records from providers, can allow patients to have better and more efficient access to their own health information.

Additionally, the APIs are to use the Health Level 7 Fast Healthcare Interoperability Resources standard to support automation of the prior authorization process. And, with this more efficient approach, the specified payors will now have a maximum of 72 hours to make prior authorization decisions for urgent requests and 7-calendar days for non-urgent requests.

Provisions of the regulations will be implemented on January 1, 2023 and January 1, 2024. The full regulation can be found here: https://www.cms.gov/files/document/11521-provider-burden-promoting-patients-electronic-access-health-information-e-prior.pdf