Discover how the latest prior authorization rules mandated by CMS can impact your business and learn how to adapt.
In the Interoperability and Patient Access final rule (85 FR 25510), CMS finalized a policy to require certain impacted payers to implement a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) Patient Access API.
CMS is proposing that payers make patient claims and encounter data (excluding cost information), data elements identified in the United States Core Data for Interoperability (USCDI) version 1, and prior authorization requests and decisions available to in-network providers beginning January 1, 2026.
Key Requiremetns
CMS is proposing to require that payers exchange patient data when a patient changes health plans. That data includes: claims and encounter data (excluding cost information), data elements identified in the USCDI V1, & prior auth requests and decisions.
Deadlines
Starting on January 1, 2026, via the already-established Patient Access API, CMS will require the payers to include information about patients’ prior authorization decisions to help patients better understand their payer’s prior authorization process and its impact on their care.
Rules
This proposed rule would also require impacted payers to report annual metrics to CMS about patient use of the Patient Access API.
Learn more about the new rules and get expert assistance.
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