CMS Interoperability Rule for Electronic Prior Auth: 10 Things to Know

The Centers for Medicare and Medicaid Services (CMS) Interoperability Rule is a new policy that aims to increase the interoperability of electronic health records (EHRs) and other health information systems. One key component of the rule is the requirement for electronic prior authorization (ePA) for certain Medicare Part D drugs. Here are 10 things to know about the CMS Interoperability Rule for ePA:

1. What is ePA? Electronic prior authorization is a process that allows healthcare providers to request prior approval for certain medications or medical procedures through an electronic system, rather than using paper forms or phone calls.
2. Why was ePA included in the CMS Interoperability Rule? The goal of ePA is to streamline the prior authorization process and improve the efficiency of healthcare delivery. It is hoped that ePA will reduce administrative burden on healthcare providers and improve patient access to needed medications.
3. What types of medications require ePA under the CMS Interoperability Rule? The CMS Interoperability Rule requires ePA for certain high-cost Medicare Part D drugs, including those that are commonly subject to prior authorization.
4. When does the ePA requirement go into effect? The ePA requirement is set to go into effect on January 1, 2026.
5. Who is required to use ePA? Under the CMS Interoperability Rule, Medicare Advantage (MA) organizations, state Medicaid and CHIP Fee-for-Service (FFS) programs, Medicaid managed care plans and Children’s Health Insurance Program (CHIP) managed care entities, and Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs), (collectively “impacted payers”) are required to comply.
6. How will ePA be implemented? The CMS Interoperability Rule requires health plans and pharmacies to use the national ePA standard, known as the FHIR standard, to transmit ePA requests and responses.
7. How will ePA benefit healthcare providers? By streamlining the prior authorization process through electronic means, healthcare providers will be able to request approval for medications more quickly and easily. This could lead to improved patient care and reduced administrative burden.
8. How will ePA benefit patients? By making it easier for healthcare providers to request prior authorization for needed medications, ePA could improve patient access to needed medications.
9. Are there any potential challenges with implementing ePA? One potential challenge with implementing ePA is ensuring that all healthcare providers and pharmacies have the necessary technology and systems in place to support it. There may also be challenges with ensuring that all relevant parties are using the same standard for transmitting ePA requests and responses.
10. Is ePA the only requirement of the CMS Interoperability Rule? No, the CMS Interoperability Rule includes a number of requirements aimed at increasing the interoperability of EHRs and other health information systems. These requirements include the ability to access and exchange electronic health information with other providers, the ability to send and receive electronic referrals, and the ability to send and receive electronic care summaries.

In conclusion, the CMS Interoperability Rule for electronic prior authorization (ePA) is a new policy aimed at streamlining the prior authorization process and improving the efficiency of healthcare delivery. The ePA requirement will go into effect on January 1, 2023 and will apply to certain high-cost Medicare Part D drugs. Health plans and pharmacies will be required to support ePA using FHIR standard. While ePA has the potential to improve patient care and reduce administrative burden for healthcare providers, there may be challenges with implementing the requirement, including ensuring that all relevant parties have the necessary technology and systems in place and are using the same standard for transmitting ePA requests and responses. The CMS Interoperability Rule includes a number of other requirements aimed at increasing the interoperability of EHRs and other health information systems.