News
- Electronic Prior Authorization Improvements: Get Involved & Start Testing
- Medicare GLP-1 Bridge Starts July 1
- CMS Extends Deadlines for GENEROUS Model Applications for Drug Manufacturers & States
- HETS Action Required: Enroll Third-Party Vendors for Access by May 11
- Open Payments: Review Your Data by May 15
- Hospitals: Report Clinical Diagnostic Laboratory Data by July 31
- DMEPOS: Send Enrollment Appeals & Rebuttals to Your National Provider Enrollment Contractor
- Medicare Shared Savings Program: Application Toolkit Materials
Compliance
Events
News
Electronic Prior Authorization Improvements: Get Involved & Start Testing
The current prior authorization process can create unnecessary delays and burden for providers. It has eroded trust between payers and providers even as we all work to ensure patients get the high quality care they need. This past summer, HHS Secretary Robert F. Kennedy, Jr., CMS Administrator Dr. Mehmet Oz, and National Coordinator for Health IT Dr. Thomas Keane announced a landmark health care industry pledge with major health plans from across the country to streamline and improve the prior authorization system. This pledge reflects a shared commitment to modernize prior authorization and create a more responsive, patient-centered health care experience.
Get Involved — Start Testing
CMS strongly encourages providers to take an active role in advancing electronic prior authorization by participating in Fast Healthcare Interoperability Resources® (FHIR) Application Programming Interface (API) testing with your electronic health record (EHR) vendor and payer partners. Contact your EHR vendor to learn how you can test to make sure your systems are ready for electronic prior authorization. Early testing and collaboration between your practice, EHR vendor, and payers is essential to ensure seamless, real-world implementation of electronic prior authorization workflows. Engage now to:
- Identify gaps
- Validate workflows
- Build the technical readiness needed to meet upcoming implementation goals
- Improve the experience for your patients and staff
Visit the new Electronic Prior Authorization webpage to get started.
Medicare GLP-1 Bridge Starts July 1
CMS is expanding access to certain GLP-1 medications for Medicare Part D beneficiaries through a short-term demonstration starting July 1, 2026. The Medicare GLP-1 Bridge will operate outside of a beneficiary’s Medicare Part D plan coverage and use a central processor for managing prior authorization, claims processing, and pharmacy payment. Eligible beneficiaries will pay $50 for drugs furnished under the Medicare GLP-1 Bridge.
For a patient to access GLP-1 medications via the Medicare GLP-1 Bridge, a medical provider must submit a prior authorization request and a prescription for an eligible GLP-1 drug for a use covered under the demonstration. Prior authorization requests will not be processed before July 1.
Visit the Medicare GLP-1 Bridge webpage to learn more, including eligibility criteria. We’ll update the webpage frequently with additional information.
More Information:
CMS Extends Deadlines for GENEROUS Model Applications for Drug Manufacturers & States
Following overwhelming interest from prescription drug manufacturers, CMS extended the application deadline for drug manufacturers to apply to the GENErating cost Reductions fOr U.S. Medicaid (GENEROUS) Model. The deadline extension to June 11, 2026, from April 30, 2026, provides interested drug manufacturers, particularly those that are small to mid-sized, with more time to engage with the CMS Innovation Center, review participation information, and prepare their application to join the model.
More Information:
HETS Action Required: Enroll Third-Party Vendors for Access by May 11
Providers using third-party vendors to check Medicare beneficiary eligibility must now enroll these vendors with CMS for HIPAA Eligibility Transaction System (HETS) access by linking each vendor to your NPI.
If you haven’t already enrolled, visit HETS EDI: How to Enroll, and follow these steps:
- Contact your vendor promptly
- Obtain their unique ID
- Use the ID to enroll and link the vendor to your NPI so they can continue submitting eligibility inquiries
Complete enrollment by May 11 to avoid service disruption.
If you opt not to enroll, you may still check eligibility through your Medicare Administrative Contractor’s secure internet portal. After enrollment, you’ll receive monthly transaction volume reports for each vendor you enrolled.
Questions?
- For report questions, contact your vendor
- If you have concerns about your NPI being misused to check eligibility, contact mcare@cms.hhs.gov
Open Payments: Review Your Data by May 15
Covered recipients: You have until May 15, 2026, to review and dispute your 2025 Open Payments™ data before CMS publishes it in June. Review is voluntary but strongly encouraged.
Register in the Open Payments system to participate in review and dispute activities:
- Review and Dispute for Covered Recipients
- Registration Quick Start Guides:
If you have questions, contact the Open Payments Help Desk at openpayments@cms.hhs.gov or 855-326-8366 (TTY: 844-649-2766).
Hospitals: Report Clinical Diagnostic Laboratory Data by July 31
Hospitals: If you bill on a 14x type of bill, you likely meet the definition of an applicable laboratory under the Clinical Laboratory Fee Schedule (CLFS). Use these resources to check your status:
- Determining Applicable Status of a Hospital Outreach Laboratory (PDF) quick reference guide
- Is My Lab an Applicable Lab? video
If you’re an applicable lab, you must report your data by July 31, 2026. Visit the CLFS & PAMA Reporting and Resources webpage for more information.
DMEPOS: Send Enrollment Appeals & Rebuttals to Your National Provider Enrollment Contractor
Starting Friday, May 8, send DMEPOS provider enrollment appeals and rebuttals to your National Provider Enrollment contractor.
For suppliers under NPEast jurisdiction – Alabama, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, Mississippi, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Vermont, Virginia, West Virginia, Wisconsin, District of Columbia, Puerto Rico, and the U.S. Virgin Islands:
Novitas Solutions, Inc
Fax: 888-213-2710
Phone: 866-520-5193
Email: NPEASTAppeals@novitas-solutions.com or NPEASTRebuttals@novitas-solutions.com
Mailing Address: Novitas Solutions, Inc; NPEast DMEPOS; P.O. Box 3704; Mechanicsburg, PA 17055-1863
For suppliers under NPWest jurisdiction – Alaska, Arizona, Arkansas, California, Colorado, Hawaii, Idaho, Iowa, Kansas, Louisiana, Minnesota, Missouri, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Texas, Utah, Washington, Wyoming, American Samoa, Guam, and the Northern Mariana Islands:
Palmetto GBA
Fax: 803-870-6761
Phone: 866-938-9652
Email: NPWest.Appeals@palmettogba.com or NPWest.Rebuttals@palmettogba.com
Mailing Address: Palmetto GBA; NPWest DMEPOS; P.O. Box 100142; Columbia, SC 29202-3142
Thursday, May 7 is the last day Chags Health Information Technology, LLC (C-HIT) will accept appeals and rebuttals. C-HIT will continue to review and decide on appeals and rebuttals submitted before the transition date.
For questions about the transition, contact ProviderEnrollmentARC@cms.hhs.gov.
Medicare Shared Savings Program: Application Toolkit Materials
Accountable Care Organizations (ACOs): See the Medicare Shared Savings Program Application Toolkit to get resources for the upcoming application submission cycle.
CMS will accept Shared Savings Program applications starting June 9 through the ACO Management System. Apply no later than noon ET on June 23.
More Information:
- Application Types & Timeline webpage
- Key Application Actions & Deadlines (PDF)
- Email questions to SharedSavingsProgram@cms.hhs.gov
Compliance
Global Surgery: Accurately Report Postoperative Visits
In a report, the Office of Inspector General found that although practitioners aren’t required to provide Medicare patients the number of postoperative visits that CMS considered in valuing the global surgery fee, overall, fewer visits are provided than are considered in the valuation.
Practitioners must report post-operative evaluation and management visits if they practice in a group of 10 or more practitioners in 1 of these 9 states: Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island. You’re exempt from required reporting if your practice has less than 10 practitioners, but we encourage you to report if possible.
See the Global Surgery (PDF) booklet for information on how to report postoperative visits in inpatient and outpatient settings.
Events
CCSQ Quarterly Stakeholder Webinar – May 12
Tuesday, May 12 from 12–1 pm ET
Register for this webinar.
You’re invited to join Dr. Dora Hughes, Chief Medical Officer of CMS and Director of the Center for Clinical Standards and Quality (CCSQ), and the CCSQ leadership team for an engaging update on our work to strengthen health care quality, safety, and coverage. Hear the latest on recent policy developments and how these efforts are accelerating progress toward improving care and outcomes for beneficiaries in Medicare, Medicaid, and the Marketplace.
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