The Centers for Medicare and Medicaid Services (CMS) finalized on Jan. 17, 2024, the CMS Interoperability and Prior Authorization Final Rule, to improve the electronic exchange of health information and prior authorization processes for medical items and services for Medicare Advantage organizations, fee-for-service, and managed Medicaid, Children’s Health Insurance Program plans, and issuers of Qualified Health Plans offered on the federally facilitated exchanges. Beginning in 2026, the rule requires payers to streamline prior authorization by setting deadlines for decisions, providing justification for denied requests, publicly reporting metrics, and implementing an application programming interface (API). Payers must also expand their current Patient Access API to include prior authorization information and implement a Provider Access API to broaden provider access to patient information beginning in 2027. These policies are expected to result in approximately $15 billion of estimated savings over ten years. Read More.
