CMS Expands on Patient Access and Interoperability Requirements for Health Plans

On December 10, 2020, CMS released a new Notice of Proposed Rulemaking (NPRM) that would expand machine-readable access to health plans’ data, building on requirements finalized in March 2020 (see our blog on the CMS Final Rule). The NPRM proposes a second phase of application programming interface (API) development for certain impacted health plans that would allow patients—and now providers—to access prior authorization data in addition to claims, encounters, and clinical data in a standardized format.

CMS’s vision is a framework within which all API requirements on plans are consistent, leveraging the FHIR standard and exchanging the same categories of data—now including prior authorization.