Unlocking opportunities through the CMS Interoperability and Prior Authorization Final Rule
In this article, Katherine Dallow, MD, Vice President and Executive Medical Director of Government Strategy of Carelon Medical Benefits Management, shares how the CMS Interoperability and Prior Authorization Final Rule will help healthcare organizations connect care and streamline experiences.
As a physician, I know how vital it is for prior authorization determinations to be made quickly. I’m happy to report that major advances are happening right now that will yield better experiences for both patients and providers.
In January 2024, the Centers for Medicare & Medicaid Services (CMS) released the Interoperability and Prior Authorization Final Rule (CMS-0057-F). For some time, prior authorization, access to electronic medical records (EMR), and fragmented health information have been pain points for everyone in healthcare. If left unaddressed, these challenges will not only compound the current lack of transparency we experience today, but they will also result in added costs and unnecessary care.
As a patient-first organization, we’re driven to advance the delivery of evidence-based, connected care to achieve affordable, whole-person health. We support the provisions of CMS-0057-F and recognize that a more efficient prior authorization process benefits everyone and prioritizes provider-patient relationships.
A complete view of member health
Limitations on access to information have been an ongoing challenge across the entire healthcare industry. Often, a member’s healthcare information, including data pertaining to prior authorizations, is siloed and only available to their current provider and health plan. If a member’s insurance coverage changes, when switching jobs for example, prior authorization history may not be readily available to their new health plan or provider — or to the member themselves.
CMS-0057-F represents the next chapter in an evolving information landscape that began with the implementation of EMRs. The new rule requires payers, providers, and entities such as Medicare Advantage and state Medicaid programs to use Fast Healthcare Interoperability Resources (FHIR)-based Application Programming Interfaces (APIs) to access health records, facilitate speedier access to data, and share patient data securely within existing HIPAA mandates. The new requirements will improve the exchange of health information between providers, payers, and patients, creating a 360-degree view of members’ care.
What’s possible with CMS-0057-F?
Faster prior authorization and facilitated information exchanges mean a better care experience and a more complete picture of members’ overall health. If members switch providers — or insurance plans — these new regulations help to ensure that healthcare information is secure and accessible to new providers. Our systems are designed to better serve patients and provide a more seamless transition for those who are already receiving treatment or who have already received approvals for procedures.
CMS-0057-F streamlines prior authorization by:
- Reducing decision times: For standard requests, the decision timeframe is seven calendar days. Expedited requests are handled within 72 hours.
- Facilitating access to relevant patient data: Providers can access the information they need within one business day. This includes claims, clinical details, and prior authorization data.
- Streamlining payer-to-payer data exchange: To promote care coordination, payers will transfer health data when members transition between insurance plans through secure, FHIR-based APIs.
- Increasing transparency: Payers will publicly report prior authorization metrics annually, which enhances transparency and facilitates informed decision making.
Our commitment to you
The CMS Interoperability and Prior Authorization Final Rule supports our efforts to simplify how healthcare information and prior authorization data are shared across a member’s healthcare journey. With the changes outlined in CMS-0057-F, we are paving the way for more seamless, connected care.
About the author
Dr. Dallow is Vice President and Executive Medical Director of Government Strategy of Carelon Medical Benefits Management. She is an internal medicine physician by training, with extensive clinical, administrative, and leadership experience.
