CMS Proposes Sweeping Expansion of Health Care Interoperability and Prior Authorization Requirements
CMS Proposes Sweeping Expansion of Health Care Interoperability and Prior Authorization ...
Summary
The US CMS published a proposed rule significantly expanding electronic prior authorization (PA) requirements, modernizing HIPAA transaction standards, and strengthening Open Payments enforcement. This affects numerous regulated entities, including Medicare Advantage and state Medicaid programs, signaling major changes in healthcare data exchange and utilization.
Details
CMS has released a proposed rule building on the 2024 final rule to expand electronic prior authorization (PA) requirements. Key provisions include mandating that insurers support electronic PA for all drugs requiring it. For medical benefit drugs, payers must integrate coverage/documentation into existing APIs using HL7 FHIR standards. For pharmacy benefits, compliance with NCPDP SCRIPT is required. Furthermore, the proposal shortens decision timeframes (e.g., 72 hours for expedited requests) and extends requirements to small group market QHP issuers on FF-SHOPs. Crucially, all impacted payers must report their API endpoints to CMS for a centralized directory, aiming to increase transparency and efficiency in data exchange. These changes accelerate standardization and digitalization within US healthcare IT.
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