Medicare/Medicaid Drug Electronic Prior Authorization: CMS Proposes Rules for 2027 Start
ADMINISTRATION OF MEDICARE/MEDICAID PROGRAMS—PROPOSED RULES - VitalLaw.com
Summary
CMS has proposed new rules regarding electronic prior authorization (PA) that include drugs. This aims to improve patient access and requires increased transparency from payers.
Details
CMS released its 2026 Interoperability Standards and Prior Authorization for Drugs proposed rule, expanding electronic PA to cover pharmaceuticals. The proposal aims to modernize drug PA by establishing clear decision deadlines for impacted payers—no later than 24 hours for urgent requests and 72 hours for standard ones—and increasing transparency through full disclosure of claims denials and appeals outcomes. Electronic PA requirements are set to expand to include drugs starting in October 2027. Impacted payers will be required to report Application Programming Interface (API) usage metrics, necessitating updates to health IT standards and implementation guides. Specifically, state Medicaid and CHIP programs must support three NCPDP standards (SCRIPT, F&B, RTPB) for drug electronic PA. Furthermore, regarding HIPAA administrative simplification, the adoption of FHIR standard and related Implementation Guides (IGs) is proposed for dental, professional, and institutional transactions related to PA. The HL7 FHIR Da Vinci CDex IG will be adopted for attachments, allowing seamless sharing of patient data in various formats (C-CDA, PDF, text files). Compliance is proposed no later than 24 months after the final rule’s effective date for HIPAA covered entities, with a longer period for small health plans.
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