The Facilities for Medicare and Medicaid Companies finalized the CMS Interoperability and Prior Authorization Rule on Wednesday. CMS stated the rule will enhance the prior authorization course of and save about $15 billion over 10 years.
The rule applies to Medicare Benefit organizations, Medicaid and the Youngsters’s Well being Insurance coverage Program (CHIP) fee-for-service packages, Medicaid managed care plans, CHIP managed care entities, and issuers of Certified Well being Plans provided on the Federally-Facilitated Exchanges.
Beginning primarily in 2026, affected payers should ship prior authorization choices inside 72 hours for pressing requests and 7 days for non-urgent requests. CMS stated that this cuts non-urgent prior authorization resolution timelines in half for some payers. Payers can even need to particularly state why they denied a previous authorization request.
“When a health care provider says a affected person wants a process, it’s important that it occurs in a well timed method,” stated HHS Secretary Xavier Becerra in an announcement. “Too many People are left in limbo, ready for approval from their insurance coverage firm. Immediately the Biden-Harris Administration is saying sturdy motion that can shorten these wait occasions by streamlining and higher digitizing the approval course of.”
Underneath the rule, payers can even need to implement a Well being Stage 7 Quick Healthcare Interoperability Assets Prior Authorization software programming interface (API). It will create a extra streamlined digital prior authorization course of between suppliers and payers.
As well as, CMS is finalizing API necessities to “enhance well being information alternate and foster a extra environment friendly well being care system for all.” CMS stated it’s delaying the dates for API coverage compliance from January 1, 2026, to January 1, 2027. Beginning in January 2027, payers can even be required to develop their present Affected person Entry API to “include details about prior authorizations and to implement a Supplier Entry API that suppliers can use to retrieve their sufferers’ claims, encounter, scientific, and prior authorization information.”
The rule additionally features a new digital prior authorization measure for eligible clinicians beneath the Advantage-based Incentive Cost System Selling Interoperability efficiency class and eligible hospitals and important entry hospitals within the Medicare Selling Interoperability Program.
A number of organizations applauded the finalization of the rule, together with the American Hospital Affiliation (AHA).
“With this ultimate rule, CMS addresses a observe that too typically has been utilized in a fashion that results in harmful delays in affected person remedy and clinician burnout within the well being care system,” stated Rick Pollack, president and CEO of the group, in an announcement. “AHA is grateful to CMS for its efforts to enhance affected person entry to care and assist clinicians give attention to affected person care relatively than paperwork.”
The Higher Medicare Alliance additionally got here out in assist of the rule.
“Higher Medicare Alliance applauds CMS for its management in modernizing the prior authorization course of and guaranteeing interoperability works for everybody. We consider these modifications serve our shared targets of defending prior authorization’s important perform in coordinating high-value care whereas additionally guaranteeing beneficiaries proceed to obtain the care they want once they want it,” stated Mary Beth Donahue, president and CEO of the Higher Medicare Alliance.
Picture: gustavofrazao, Getty Pictures
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