CMS Rule Targets Prior Authorization With Interoperability

The “CMS Interoperability and Prior Authorization” rule will allow certain payers, providers, and patients to have electronic access to pending and active prior authorization decisions. This is expected to cut back on repeated requests for prior authorizations, thereby reducing costs and administrative burden so providers can deliver higher quality care.

This final rule requires the payers regulated under this rule—Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs (FFS) and issuers of individual market Qualified Health Plans (QHPs) on the Federally-facilitated exchanges (FFEs)—to use application programing interfaces (APIs) that will give providers better access to data and make the process of prior authorization more efficient.

In addition to improving the convenience of health information access, the implementation of APIs will reduce the inefficiencies of the prior authorization process for providers through automation.