The CMS’ Advancing Interoperability and Improving Prior Authorization Proposed Rule: A Guide for Payers and Providers
How the CMS Advancing Interoperability and Improving Prior Authorization new proposed rule will change the payer and provider landscape
The Centers for Medicare and Medicaid Services (CMS) has proposed new requirements designed to improve two fundamental features of healthcare: the interoperability of healthcare payers and providers and the prior authorization process as it pertains to patients and their payers and providers.
When effective, the new CMS rule would introduce changes to the payer-provider landscape, including, though not limited to:
- New and improved FHIR APIs.
- New visibility for patients and providers into prior authorization requests.
- Requirements for payers to provide relevant documentation on prior authorization decisions to patients and their providers in a timely manner.
- A standard FHIR Payer-to-Payer Data Exchange.
- New data sharing from payers to providers to enable providers with a more complete view of the care patients receive – in some cases in advance of patient visits.
- New measures for electronic prior authorizations for eligible clinicians under the Promoting Interoperability Performance category of MIPS and for eligible hospitals and critical access hospitals (CAHs) under the Medicare Promoting Interoperability Program.
Download this guide for payers and providers to prepare for the rule taking effect on January 1, 2026. It is essential that payers do not delay planning and implementation to comply with this rule. CMS has also proposed that payers will have reporting requirements starting March 31, 2025.