New CMS Proposed Rule: Interoperability & Electronic Prior Authorization

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Prior authorization is a challenge for both providers and patients. The new CMS proposed rule on interoperability and electronic prior authorization aims to decrease provider abrasion and enhance the member experience – and ultimately improve both member and population health.

Today’s prior authorization challenges

Prior authorization hinges on accurate data and easy access to that data.  Today, the exchange of information between providers and insurance is often challenging and convoluted, and the processes for prior authorizations are no different.  Determining which services and procedures require prior authorization and what supporting documentation is needed to reach a decision often delays the delivery of care.

Many providers still rely on fax to get the prior authorization information to and from the insurance company. Providers send the information, wait for a response from the health insurance plan, send the requested information, wait for a response, and so on.

In a world, where nearly anything can be instantaneously ordered and delivered overnight, from your mobile phone or laptop, it seems inconceivable that prior authorizations, something so critical to member and population health, is managed by such a slow, tedious, and antiquated system.

Interoperability in healthcare data is poised to close the gap.


How can interoperability make prior authorizations less painful?

Interoperability offers the possibility of streamlining the prior authorization process with the seamless interchange of data via APIs, in real time. The new CMS rule proposes requiring implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization. With this:

  • Providers can easily find out if a prior authorization is required for a patient/procedure
  • If yes, providers can then see the documentation requirements for that prior authorization

For example, if a member needs an endoscopy, the API pulls the information and tells the provider what information is required for the prior authorization.

Furthermore, since the early 2010s, most provider offices have electronic health records. This API would facilitate linking the electronic records to the prior authorizations and exchanging the information that needs to be shared between the provider and insurance.

This seamless exchange of data will reduce provider abrasion, improve the member experience and potentially their health outcome, and ultimately decrease the cost of care – as the manual effort and time linked to prior authorizations markedly decreases.

Patient Access API

The CMS Interoperability final rule which has been in effect since January 1, 2021, and CMS began enforcing as of July 1, 2021 included the Patient Access API and the proposed rule looks to expand the scope.

The Patient Access API enables a Medicare Advantage (MA), Medicaid, Children’s Health Insurance Program (CHIP), and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs) member to access their healthcare information using smart apps of their choice.

The proposed rule adds prior authorizations and decisions to the information available via the Patient Access API along with annual metrics of prior authorization requests and decisions on the plan or issuer’s website.

Member health information is a mountain of data – a lifetime of different doctors, procedures, and experiences. You move or change doctors – sometimes you collect your health records and sometimes they’re lost to the shuffle of life. All this data, in so many different places, makes it challenging for members and their providers to understand and analyze it all.

Extending the interoperability API to members puts all their health data at their fingertips – across doctors, geography, and time – empowering members and populations to improve their health.

Provider Access API

For providers, there’s the possibility of sharing patient data within a network of providers. Members can grant providers access to share their data – empowering the providers to better collaborate and see the full picture of a member’s health and medical experience. This could ultimately improve patient outcomes.

The Proposed Rule also looks to return focus on the Payer to Payer Data Exchange rules which CMS deferred enforcement to allow for creation of supporting structure and standards. The Payer to Payer Data Exchange required a plan or issuer to share up to 5 years of membership and claims information for a member when the member moved to a new plan or issuer, upon the members request. CMS is proposing to also allow a member with concurrent coverages to request the plans or issuers to exchange the data quarterly. The addition of prior authorization requests and decisions to the data exchanged is also proposed.

HealthEdge: On the Forefront of Interoperability

The HealthEdge suite of products are built on solid processes that produce accurate, real-time data. With this data, providers and plans can easily access data and improve population health, increase customer satisfaction, and decrease provider challenges. Learn more here.