Whitepaper
Preparing for the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)
Oct. 15, 2024 · Authored by Heather L. Herc
Is your health plan ready for CMS’ Interoperability and Prior Authorization final rule?
With healthcare's ongoing push toward patient-centered care, the Centers for Medicare & Medicaid Services (CMS) has finalized a pivotal regulation that will reshape how health plans handle data exchange and prior authorizations. The CMS Interoperability and Prior Authorization final rule (CMS-0057-F) introduces new requirements that aim to improve patients’ access to their own health data, reduce administrative burdens, and enhance the prior authorization process. As deadlines approach—starting in January 2026—it's critical for government-sponsored health plans to act now to ensure compliance.
A new era of healthcare interoperability
The CMS-0057-F Final Rule builds on previous efforts, like the Interoperability and Patient Access Final Rule from 2020. While the earlier rule laid the groundwork by mandating patient data access, this new rule goes further by introducing specific policies for sharing prior authorization information and expanding the role of APIs in health data management. This means health plans will need to adopt new technology, streamline processes, and improve transparency for patients, providers, and other stakeholders.
Key highlights of the CMS-0057-F final rule:
- Patient and provider access APIs: Health plans will be required to provide easy access to patient data, including prior authorization details, via third-party apps. This enhances the patient's experience and improves care coordination with healthcare providers.
- Payer-to-payer data exchange: Plans must facilitate data sharing between health plans at a patient’s request, ensuring seamless continuity of care.
- Prior authorization API: Automating and expediting prior authorization requests will alleviate burdens on providers while offering patients quicker decisions on their healthcare needs.
These changes are set to roll out in phases, with major deadlines in January 2026 and January 2027, meaning health plans must act now to develop a strategic implementation plan.
