The Centers for Medicare & Medicaid Services (CMS) recently released a final rule aimed at improving healthcare data sharing and streamlining prior authorization processes. This rule, known as the Interoperability and Prior Authorization final rule (CMS-0057-F), is expected to benefit patients, providers, and payers alike. Payers included in the final rule include Medicaid Managed Care plans and State Medicaid agencies.

Key Highlights of the Rule: 

  • Enhanced Patient Access API: Payers will be required to add information about prior authorizations (excluding drugs) to their existing Patient Access API. This includes details like status, approval/denial reason, and related documentation. Patients will be able to access this information conveniently through apps and other patient-facing tools. 
  • New Prior Authorizations API: This API will provide a standardized way for providers to submit prior authorization requests and receive electronic responses. The rule mandates the use of FHIR APIs for these transactions, promoting interoperability and reducing administrative burden. 
  • Faster Prior Authorization Decisions: Payers must decide on prior authorization requests within stricter time limits: 72 hours for expedited requests and 7 days for standard requests. This represents a significant reduction in the turnaround time for some payers and ensures consistency of timing for providers and patients. 
  • Improved Transparency: Payers must now provide specific reasons for denying prior authorization requests, regardless of the communication method. This increased transparency aims to improve communication and facilitate appeals. 
  • Public Reporting: Payers will be required to publicly report key prior authorization metrics annually, including approval/denial rates and processing times. This data will be valuable for assessing progress and identifying areas for further improvement. 

Implementation Timeline: 

  • Most provisions of the rule go into effect on January 1, 2027, allowing payers and providers time to adapt. 
  • Public reporting of prior authorization metrics begins on January 1, 2026. 
  • Development and enhancement of the prior authorization API is required by January 1, 2027. 

Overall Impact: 

The CMS Interoperability and Prior Authorization final rule is expected to bring significant benefits to the healthcare system: 

  • Improved patient access to their health information: Patients will have easier access to their prior authorization details, empowering them to participate more actively in their care. 
  • Reduced administrative burden on providers: Streamlined prior authorization processes and standardized electronic transactions will save providers valuable time and resources. 
  • Enhanced communication and transparency: Clearer communication of prior authorization decisions and public reporting will improve understanding and collaboration between patients, providers, and payers. 
  • Better healthcare outcomes: Faster access to necessary care and improved communication are likely to lead to better health outcomes for patients. 

How Telligen Can Help: 

Being a Utilization Management (UM) clinical services and system vendor, Telligen is uniquely positioned to help our State Medicaid payer clients comply with the CMS Prior Authorization Rule and realize its benefits in support of whole-person care. Our Qualitrac suite of products offers several solutions: 

  1. Enhanced Patient Access API: Qualitrac can easily integrate with your existing Patient Access API to include information about prior authorizations, such as case status, approval/denial reason, and related documentation. We already offer similar information via “Review status chatbots” for our clients. 
  2. FHIR API Expertise: Telligen has extensive experience with FHIR APIs for prior authorizations. We have conducted pilot projects and joint demonstrations with partners at HL7 FHIR Connectathons. This experience allows us to help clients by implementing the new FHIR API requirement and meet the CMS deadlines smoothly. 
  3. Faster Prior Authorization Decisions: Telligen’s innovative methods, like provider gold-carding and auto-authorization rules, have already reduced prior authorization decision wait times for our clients. We can help you meet and even exceed the new CMS time limits. 
  4. Enhanced Transparency: We understand the importance of transparency. Telligen currently responds to denials in writing, informing both providers and members promptly to keep them in the loop. This practice already aligns with the CMS rule’s transparency requirements. 
  5. Public Reporting Support: Telligen will provide user-friendly dashboards for our clients, displaying the status of prior authorizations along with predictive and prescriptive analytics. These tools will make public reporting effortless and ensure you comply with the regulations. 

This rule represents a major step forward in promoting interoperability and streamlining administrative processes in healthcare. While compliance requires some adaptation, the long-term benefits for all stakeholders are significant. With Telligen as your partner, you can navigate the new CMS Prior Authorization Rule confidently and reap its benefits for improved patient care, reduced administrative burden, and greater transparency.