CMS announces proposed rule to improve electronic data exchange and streamline prior authorization


doctor on tablet

On December 11, 2020, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule designed to improve electronic health care data exchange and streamline the prior authorization process. The CMS fact sheet accompanying the proposed rule stated that its goal is “reducing overall payer and provider burden and improving patient access to health information.”

The proposed rule includes five sets of proposals and five requests for information. The proposals include the following:

  1. Patient Access Application Programming Interface (API) – This proposal builds on the Interoperability and Patient Access final rule, which required certain payers to implement a Fast Healthcare Interoperability Resources-based Patient Access API. CMS would now require these payers to include information about patients’ pending and active prior authorization decisions in the API. These payers would also be required to maintain an attestation process for third party application developers to attest to certain privacy policy provisions prior to retrieving data via the API and to report metrics on patient use of the API quarterly.
  2. Provider Access APIs – CMS proposes that certain payers build and maintain Provider Access APIs for payer-to-provider data sharing of claims and encounter data in order to better facilitate coordination of care.
  3. Documentation and Prior Authorization Burden Reduction through APIs – This proposal includes several policies designed to make the prior authorization process more efficient and transparent and to make the process less of an administrative burden for providers. CMS would require impacted payers to (1) maintain a document requirement lookup service API that could be integrated with provider EHRs; (2) maintain a prior authorization support API that can send requests and receive responses electronically within existing workflows; (3) include specific reasons for denials when denying prior authorization requests; (4) send prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests; and (5) publicly report certain information regarding their prior authorization process.
  4. Payer-to-Payer Data Exchange on Fast Healthcare Interoperability Resources (FHIR) – This proposal builds on the Interoperability and Patient Access final rule, which required CMS-regulated payers to exchange and maintain certain health information and encouraged the use of FHIR-based APIs. CMS would now require the use of such APIs and would expand the categories of data that must be exchanged to include claims and encounter data. CMS would also encourage payers to consider information from previous payers when making new prior authorization determinations.
  5. Adoption of Health IT Standards and Implementation Specifications – Finally, the Office of the National Coordinator for Health IT (ONC) would adopt, on behalf of HHS, the implementation specifications described in existing regulations (45 CFR 170.215) as standards and implementation specifications for health care operations. This would result in a unified CMS-ONC approach that would create a “nationwide health information technology infrastructure that supports reducing burden and health care costs and improving patient care.”

The requests for information include (1) methods for enabling patients and providers to control the sharing of health information; (2) electronic exchange of behavioral health information; (3) reducing burden and improving electronic information exchange of documentation and prior authorization; (4) reducing the use of fax machines for health care data exchange; and (5) accelerating the adoption of standards related to social risk data.

The comment period for these proposed rules and requests for information will close on January 4, 2021.

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