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CMS Proposes to Streamline Prior Authorization, Patient Access to Data

In a new rule, the Centers for Medicare & Medicaid Services (CMS) proposes changes to improve patients’ access to their electronic health information and reduce burden on providers related to prior authorization.

The rule builds on a CMS final rule on interoperability and patient access that required Medicare Advantage plans, state Medicaid fee-for-service (FFS) and managed care plans, qualified health plans (QHPs) sold on Affordable Care Act exchanges, and certain other payers to increase access to health information through application programming interfaces (APIs). APIs allow applications, such as mobile apps, to access information in an electronic health record or other database.

The proposed rule seeks to leverage the use of APIs by Medicaid FFS and managed care plans, Children’s Health Insurance Program FFS and managed care plans, and individual market QHPs by:

  • requiring payers to include prior authorization information in patient access APIs;
  • mandating that payers create a provider access API to allow better payer-to-provider data sharing of claims and encounter data, as well as sharing of active and pending prior authorization decisions;
  • leveraging APIs to allow providers to submit prior authorization requests and receive responses electronically;
  • facilitating payer-to-payer data exchange using the Fast Healthcare Interoperability Resources (FHIR) standard; and
  • adopting health information technology implementation standards and specifications related to health care operations.

In addition to the proposals above, the rule requests information in five areas:

  • enabling patients and providers to control sharing of health information;
  • advancing the exchange of behavioral health information;
  • reducing burden and improving electronic information exchange of documentation and prior authorization, including adding an improvement activity under the Merit-based Incentive Payment System to suppose the use of a prior authorization support API by providers;
  • encouraging the adoption of standards related to social risk factors; and
  • reducing the use of fax machines for exchanging health information.

If finalized, the rule’s provisions would take effect in January 2023. Comments on the rule were due Jan. 4, 2021.

Contact Senior Director of Policy Erin O’Malley at or 202.585.0127 with questions.


About the Author

Shahid Zaman is a senior policy analyst at America's Essential Hospitals.

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