Introducing the New CMS Proposed Rule “Advancing Interoperability and Improving Prior Authorizations” and What It Means for Impacted Parties
By Michael Gould, Associate Vice President of Interoperability Strategy at ZeOmega
The proposed rule specifically calls for the HL7 FHIR version 4.0.1, the US Core FHIR profile, and the Smart Application Launch Framework. The proposed rule calls for a single FHIR Prior Authorization Requirements, Documentation, and Decision API (PARDD API) without requiring specific FHIR implementation guides to meet this requirement. For the FHIR PARDD API, CMS recommends the use of the existing Coverage Requirements Discovery (CRD), Document Templates and Rules (DTR), and Prior Authorization Support (PAS) FHIR implementation guides from the HL7 Da Vinci Project. CMS is strongly recommending rather than requiring the use of specific FHIR implementation guides. Before requiring their use, CMS will monitor the progress made in refining, testing, and implementing FHIR PARDD APIs with these implementation guides.
The new proposed rule also makes changes to require what data are to be included in APIs by making specific reference to the ONC requirement of USCDI. As ONC is the custodian of USCDI, by referring to the ONC requirement of USCDI, CMS now aligns with ONC as future versions of USCDI are adopted and ensures the data payers are to include in required APIs follows future versions of USCDI.
CMS is reissuing two preexisting requests for information (RFIs):
- Accelerating the Adoption of Standards Related to Social Risk Factor Data
- Focusing on social risk factors (e.g., housing instability, food insecurity) and their relationship to patient health and healthcare utilization, CMS is seeking information on barriers to adopting standards for the social risks of health. CMS views these data as important in value-based care and that standards will facilitate data sharing, particularly for providers that depend on high-quality social risk data.
- Electronic Exchange of Behavioral Health Information
- To inform future, potential rulemaking to advance electronic data exchange among behavioral health providers, CMS is seeking comments on how APIs might be used, as electronic data exchange among behavioral health providers has lagged compared to other types of providers.
CMS also proposes three new RFIs:
- Improving the Electronic Exchange of Information in Medicare Fee-for-Service (FFS)
- Different providers often order, render, or supply items and services to Medicare FFS beneficiaries. Sharing of information among these providers or suppliers could be improved to enhance treatment, coordination of care, and ensure accurate and timely payment. CMS is seeking comment on how to improve the exchange of medical documentation among these providers and patients.
- Advancing Interoperability and Improving Prior Authorization Processes for Maternal Health
- CMS is seeking comment on how health IT, data sharing, and interoperability would improve maternal health outcomes. Additionally, CMS is seeking specific comments on how to leverage USCCI in maternal health and improve prior authorization policies that can negatively impact maternal health outcomes.
- Request for Information: Advancing the Trusted Exchange Framework and Common Agreement (TEFCA)
- Prior to CMS publishing this proposed rule, the Office of the National Coordinator for Health IT (ONC) released the Trusted Exchange Framework and Common Agreement (TEFCA). CMS is seeking comment on how TEFCA supports and advances provisions proposed in this rule, as well as those in the Patient Access and Interoperability final rule of 2020. Additionally, CMS seeks comment on approaches to incentivize and encourage payers to enable exchange under TEFCA.
In the Advancing Interoperability and Improving Prior Authorization proposed rule, CMS identified the following programs to comply:
- Medicare Advantage Organizations
- Medicaid Managed Care Plans
- State Medicaid Agencies
- Children’s Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities
- Issuers of Qualified Health Plans on the federally facilitated Exchanges (FFEs) (exclusive of Stand-Alone Dental Programs (SADP) and federally facilitated Small Business Health Options Program Exchanges (FF-SHOP))
- Merit-based Incentive Payment System (MIPS) Eligible Clinicians (under the Promoting Interoperability performance category of MIPS)
- Eligible Hospitals and Critical Access Hospitals in the Medicare Promoting Interoperability Program
The list of covered entities is greater than those originally in the Interoperability and Patient Access Final Rule of 2020 or the December 2020 CMS Interoperability proposed rule. MIPS-eligible clinicians and critical access hospitals were added in direct response to comments received on the December 2020 proposed rule.
Overall, the proposed timeframe to effective dates is intended to allow sufficient time for the impacted parties to plan and implement by the effective dates, taking into account states’ abilities to secure funding and qualified technical staff. While Medicare FFS is not included, CMS does seek comment on how the proposed provisions could apply to Medicare FFS. CMS also encourages other payers who are not directly impacted by this proposed rule to evaluate these proposals for voluntary adoption.
ZeOmega’s Jiva healthcare enterprise management platform provides a holistic, person-centric approach to health management and helps organizations meet evolving CMS requirements and succeed with value-based care. Contact ZeOmega to learn more.
Smart Authorization Gateway is the part of the HealthUnity portfolio that is available to help payers and providers meet interoperability compliance mandates – and beyond.