January 23, 2024
On January 17, the Centers for Medicare & Medicaid Services (CMS) issued its Interoperability and Prior Authorization final rule, which sets requirements related to the electronic exchange of health information and prior authorization processes for government-regulated health plans. For the last several years, the ACS has been urging CMS to finalize many of the requirements contained in this rule.
Starting in 2026, impacted plans must send prior authorization decisions within 72 hours for urgent requests and within 1 week for nonurgent requests. Plans also will be required to disclose specific reasons for denying prior authorization requests and annually publish certain prior authorization metrics, such as approval/denial rates and average processing times, on their public-facing websites.
In addition, CMS will require plans to implement and maintain application programming interfaces (APIs) for prior authorization beginning in 2027. Such APIs must allow providers to complete prior authorization requests via electronic health records (EHRs) and be populated with plans’ lists of covered items and services, as well as documentation requirements for prior authorization approval. APIs will also help facilitate communication about whether a plan approves a prior authorization request (and the date or circumstance under which the authorization ends), denies a prior authorization request (and a specific reason for the denial), or seeks more information from the provider.