CMS Interoperability and Prior Authorization Final Rule CMS-0057-F
The Centers for Medicare & Medicaid Services (CMS) affirms its commitment to advancing interoperability and improving prior authorization processes by publishing the CMS Interoperability and Prior Authorization final rule (CMS-0057-F). Through the provisions in this final rule, Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) Fee-for-Service (FFS) programs, Medicaid managed care plans, and CHIP managed care entities.
Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs) (collectively “impacted payers”) are required to implement and maintain certain Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) application programming interfaces (APIs) to improve the electronic exchange of health care data, as well as to streamline prior authorization processes.
This final rule aims to motivate healthcare providers to utilize electronic prior authorization processes. As per the rule, a new measure has been added for MIPS eligible clinicians in the Promoting Interoperability performance category of MIPS, and also for eligible hospitals and critical access hospitals (CAHs) under the Medicare Promoting Interoperability Program. Learn More
