Doctors discussing patient care while walking through a hospital.

Prior Auth - (PARDD) API

The proposal applies to payer processes mainly in public programs, with more limited application to health insurance marketplaces and no requirements on employer-sponsored coverage.

Who do these new requirements apply to?

Medicare Advantage plans, Medicaid managed care plans, Medicaid fee-for-service (FFS) plans, Children’s Health Insurance Program (CHIP) managed care and fee-for-service arrangements, and Qualified Health Plans (QHP) on the federally facilitated health insurance marketplace (i.e., healthcare.gov).

A female doctor is having a conversation with her male patient about his health

What are the implementation requirements?

CMS proposed to require affected payers to use a specific Application Programming Interface (API) to allow for more streamlined prior authorization processes. The specific API is called the “Fast Healthcare Interoperability Resources® (FHIR) Prior Authorization Requirements, Documentation, and Decision API” (or PARDD API).

The new Prior Authorization Rule are requiring
FHIR, X12, and CDA standards

Diagram about the proposed rule from CMS

CMS is proposing a FHIR API (PARDD API) that would automate the process for providers to determine whether a prior authorization is required, identify prior authorization information and documentation requirements, as well as facilitate the exchange of prior authorization requests and decisions from their EHRs or practice management system.

Both X12 and CDA standards are proposed for the exchange of documents and digital signatures during the prior authorization process.

Denial Reason
‍

Include a specific reason when payors deny a prior authorization request, regardless of the method used to send the prior authorization decision.
This will facilitate better communication and understanding between the provider and payer and, if necessary, a successful resubmission of the prior authorization request.

Prior Authorization Time Frames

Require impacted payers (not including QHP issuers on the FFEs) to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests.
However, CMS is also seeking comment on alternative time frames with shorter turnaround times, for example, 48 hours for expedited requests and five calendar days for standard requests.

Prior Authorization Metrics

Require impacted payers to publicly report certain prior authorization metrics by posting them directly on the payer’s website or via publicly accessible hyperlink(s) on an annual basis.
If finalized, these prior authorization policies would take effect January 1, 2026, with the initial set of metrics proposed to be reported by March 31, 2026.

Are there other pieces to this proposed rule?

The proposal builds on earlier rulemaking, including a May 2020 final rule on interoperability and a now withdrawn interoperability regulation from December 2020.

Two healthcare professionals reviewing a patient chart on a tablet

Patient information access

Require 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.

Provider information access

Require impacted payers to build and maintain a Provider Access API to share patient data with in-network providers with whom the patient has a treatment relationship

Payer-Payer data exchange

At a patient’s request, certain impacted payers must exchange certain patient health information when a patient changes health plans, and maintain that information, thus creating a longitudinal health record for the patient that is maintained with their current payer.

Two doctors discussing a patient's test results