CMS Readies Providers for Interoperability and Prior Authorization Rule

McKnight’s Home Care | By Adam Healy

The Centers for Medicare & Medicaid Services offered providers resources to help prepare for the newly finalized Interoperability and Prior Authorization final rule, which will go into effect in 2026. 

“In this rule, we explore ways that technology can improve and streamline the complex process of prior authorization,” Alexandra Mugge, deputy chief health informatics officer and director of CMS’ health informatics and interoperability group, said during a webinar last week. “By improving prior authorization processes for providers, we hope that they will be able to put that time back into taking care of their patients. So this would have a direct impact on the provider and saving time, but hopefully they can put that time into patient care, which will have a significant impact on the patient, as well.”

The rule is primarily focused on streamlining healthcare data sharing by using specialized application programming interfaces (APIs), tools that allow programs or applications to communicate with each other, Mugge explained. CMS’ rule will create multiple APIs for patients, providers and payers, which would “greatly improve data sharing and access to information” among these parties, she said.

Home care and hospice providers have generally not benefited from interoperable health data technology and, as a result, lack critical information about their patients. A specialized “Provider Access API” finalized in CMS’ rule would give all providers the ability to see their patients’ claims and encounter data, as well as their prior authorization information, another key focus of the rule.

“Automation and technological solutions are never enough to address a complex process like prior authorization,” Mugge said. “To truly look at prior authorization reform, we have also looked at … cultural changes that will help to support streamlining these processes in the future, in addition to the technology solutions.” 

These changes include reduced prior authorization decision timelines and a requirement that payers provide a specific reason for denials, according to the rule. Specifically, the rule requires certain payers — such as MA, Medicaid and Medicaid managed care plans — to make prior authorization decisions within 72 hours for expedited requests, and within one week for standard, non-urgent requests.

Meanwhile, some critics have called on CMS to reduce decision timelines even further. The Improving Seniors’ Timely Access to Care Act, which has been endorsed by LeadingAge, would require Medicare Advantage plans to make prior authorization decisions within 72 hours of a request.