CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)

CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)
CMS Advancing Interoperability and Improving Prior Authorization Proposed Rule (CMS-0057-P) - feature

CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)

The Centers for Medicare & Medicaid Services (CMS) released the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) on January 17, 2024. This final rule emphasizes the need to improve health information exchange to achieve appropriate and necessary access to health records for patients, healthcare providers, and payers. This final rule also focuses on efforts to improve prior authorization processes through policies and technology, to help ensure that patients remain at the center of their own care.

The rule enhances certain policies from the CMS Interoperability and Patient Access Final Rule (CMS-9115-F) and adds several new provisions to increase data sharing and reduce overall payer, healthcare provider, and patient burden through improvements to prior authorization practices and data exchange practices.

Impacted payers are required to implement certain provisions by January 1, 2026. However, in response to stakeholder comments on the proposed rule, impacted payers have until primarily January 1, 2027, to meet the application programming interface (API) requirements in this final rule.

View the Final Rule in the Federal Register here
 

 

Additional Resources

Link

Recording (password: 5PAMV^vN) and slides (PDF) from the CMS Interoperability and Prior Authorization final rule informational session held March 26, 2024

Link

Frequently Asked Questions about past CMS Interoperability rules


 


Guidance

February 28, 2024: The National Standards Group (NSG) announced an enforcement discretion for Health Insurance Portability and Accountability Act (HIPAA) covered entities that implement Fast Healthcare Interoperability Resources® (FHIR®) based Prior Authorization APIs as described in the CMS Interoperability and Prior Authorization final rule. In response to the final rule, NSG will not take HIPAA Administrative Simplification enforcement action against HIPAA covered entities that choose not to use the X12 278 standard as part of an electronic FHIR prior authorization process.

Read the enforcement discretion

Read enforcement discretion FAQs (PDF)


Page Last Modified:
07/01/2024 11:27 AM