CMS Proposes Interoperability Standards for Drug Prior Authorization
CMS Proposes to Update Interoperability Standards - America's Essential Hospitals
Summary
The Centers for Medicare & Medicaid Services (CMS) proposed a rule to introduce interoperability standards into the drug prior authorization process. This mandates that impacted payers provide electronic prior authorization capabilities and utilize specific HL7 FHIR resources.
Details
On April 14, 2026, CMS issued a proposed rule aimed at adding interoperability standards for drug prior authorization. The rule requires impacted payers to make electronic prior authorization available for drugs and apply decision timeframes to drugs without established ones. Furthermore, payers must report API endpoints and related information to CMS. Technically, the proposal mandates the use of certain Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR) implementation guides relevant to prior authorizations. The Office of the National Coordinator for Health Information Technology (ONC) is expected to adopt updated versions of these standards, incorporating CMS' interoperability requirements. The proposed rule emphasizes the critical need for standardized data exchange and process automation in U.S. healthcare IT, a topic highly relevant to global health systems including Japan.
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