On January 15, 2021, the Centers for Medicare & Medicaid Services (“CMS”) issued the final rule for CMS Interoperability and Prior Authorization (the “Final Rule”) to improve the prior authorization process and give patients more control in accessing and understanding their health information. Under the Final Rule, certain payers, such as Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service (“FFS”) programs and those that issue individual market qualified health plans (“QHPs”) on the federally-facilitated exchanges (“FFEs”) must develop and implement technology known as application programming interfaces (“APIs”). APIs are commonly used in smartphone applications, and when incorporated into electronic health records (“HER”), can enable simple and immediate access to health information for providers.
Each payer covered by the Final Rule must create a documentation search capability driven by an API, and make the program public, allowing providers to access health documentation and prior authorization requirements from various EHR platforms. Once a provider determines what each prior authorization requires, the authorization can then be submitted electronically. Payers are also required to provide, under the already established patient access API, laboratory results and other claims and encounter data, as well as information regarding a patient’s pending and active prior authorizations.
Payers are also required to share this data with a patient’s provider if requested, and with other payers, in circumstances where a a patient’s coverage or provider changes. This requirement will allow patients, providers, and payers to have access to all the necessary data when needed, automating the process and reducing the administrative burden on providers. As a result, providers will be less likely to work with incomplete health information and the likelihood of repeat prior authorization requests will decrease, resulting in more time the provider has to spend with the patient. Notably, Medicare Advantage plans are not subject to the requirements of the Final Rule; however, CMS is continuing to consider whether Medicare Advantage plans should be included.
Under the Final Rule, payers will have up to 72 hours to make prior authorizations on urgent requests, and 7 calendar days for non-urgent requests. All payers covered by the Final Rule must provide an exact reason for any denial, giving providers increased transparency in the authorization process. To further encourage accountability, payers are also required to make public statistics related to prior authorizations that illustrate how the payer operates its prior authorization process.
The Final Rule will benefit patients as well; patients will have a better understanding of the prior authorization process, and will be able to better coordinate with their provider to properly plan for their healthcare needs. Patients will also have easier access to their health information and can take their information with them as they change plan