Knowledge Center

Written by Robert Tennant, VP Federal Affairs, WEDI

WEDI was pleased to have Alexandra Mugge, the Chief Health Informatics Officer and Director at the Centers for Medicare & Medicaid Services, provide an in-depth walkthrough of the recently finalized CMS Interoperability and Prior Authorization Final Rule. The session outlined the key provisions of the regulation, including:

• The impacted payers in the final rule are Medicare Advantage organizations, Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans on Federally-Facilitated Exchanges.
• The rule’s requires the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) for the payer-to-payer Application Programming Interface (API), the Provider FHIR API, and the Patient FHIR API.
• The rule mandates the implementation of a HL7 FHIR API to automate the prior authorization process for providers and payers.
• The new prior authorization process involving three separate APIs: (i) Coverage Determination Discovery (CRD); (ii) Document Templates and Rules (DTR); and (iii) Prior Authorization Support (PAS).
• By 2026, payers will need to respond within 72 hours for urgent authorization requests and seven days for standard authorization requests and must also provide specific reasons for denying prior authorization requests to facilitate resubmissions or appeals.
• Payers will be required to publicly report their prior authorization metrics.
• CMS is providing flexibility for covered entities using an all-FHIR-based Prior Authorization API regarding the current required use of the HIPAA X12 278 transaction standard.
• As an incentivize for providers to adopt FHIR API technology, CMS introduced a new measure for eligible clinicians and hospitals to report their use of Prior Authorization APIs under the Merit-based Incentive Payment System and Medicare Promoting Interoperability Program.
• The required and recommended HL7 Implementation Guides for each of the data exchange and prior authorization FHIR APIs.
• The required compliance dates, ranging from 1.1.26 for some provisions to 1.1.27 for others.

The second half of the program saw a wide variety of audience questions on the final rule addressed by Ms. Mugge. WEDI leadership discussed next steps for the organization to assist the industry implement this complex rule. WEDI is offering deep dive webinars on the data exchange and prior authorization sections of the final rule as well as sessions aimed at small provider and small payer organizations.

Finally, WEDI outlined some of the lessons learned from the implementation pf Version 5010 of the HIPAA transaction standards and the ICD-10 code and how those lessons would be applied to adoption of FHIR APIs. Download the recording of the event and access the slides here.