CMS Prior Authorization Final Rule

Clarification of information regarding the Prior Authorization Final Rule:

• The CMS Interoperability and Prior Authorization Final Rule CMS-0057-F applies to electronic processing of medical services and items only.  This does not apply to Part D Drugs. 
• There is a proposed rule that would be inclusive of prior authorizations for prescription drugs, but it has not been finalized yet. Public comments are open until June 15, 20206. 
• The link to this proposed rule is: 2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule (CMS-0062-P) | CMS

 Regarding which payors must comply with this Final Rule as of January 1, 2027: 

• All Medicare Advantage organizations, State Medicaid and CHIP FFS plans, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers are required to process all medical service and items prior authorizations electronically.

To prepare for this, if your office accepts any of these payors, your EMR/EHR must be compliant with this process. 

•  The only commercial payors affected are the QHPs offered on Federally-Facilitated Exchange (FFE).  Pennsylvania does not utilize the FFE for our QHPs.  I'm sure you are all aware of Pennie, which is our State sponsored Marketplace Health Plan site.
• This rule does not apply to Medicare Fee-For-Service plans.

• All other health plans may voluntarily implement this policy and procedure, but they are not required as of January 1, 2027.  CMS reports that some commercial payors have pledged to participate, but there is no formal commitment as of now.
• More information is outlined in this link: CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) | CMS

 CMS recommends that physician offices take these steps now:

1. Talk to your EHR vendor to confirm readiness. Ask questions to help you understand their implementation roadmap, including:
• What’s our implementation timeline?
• What are our EHR system’s API integration and electronic prior authorization capabilities?
• Is our current EHR certified to support the necessary functionality?
• What specific features are you building for:
• Payer Prior Authorization API integration?
• Electronic prior authorization workflows?
• Seamless data exchange?
• Will we need to upgrade our system or purchase additional modules?
• What testing opportunities will you provide?
• What training and technical support will you offer?
• Are you participating in pilot programs with payers?
2. Upgrade your technology, including EHR templates and workflows, if needed. Your vendor can give you information and support.
3. Start testing: We strongly encourage providers to take an active role in advancing electronic prior authorization by participating in Fast Healthcare Interoperability Resources® (FHIR) API testing with your EHR vendor and payer partners. Contact your EHR vendor to learn how and when you can begin testing to make sure your systems are ready for electronic prior authorization. Early testing and collaboration between your practice, EHR vendor, and payers is essential to ensure seamless, real-world implementation of electronic prior authorization workflows. Engage now to:

      Testing Resources:

• Identify gaps
• Validate workflows
• Build the technical readiness needed to meet upcoming implementation goals
• Improve the experience for your patients and staff
• Office of the National Coordinator for Health Information Technology (ONC)-supported DaVinci Inferno test kits:

• Coverage Requirements Discovery
• Documentation Templates & Rules
• Prior Authorization Support

• HL7 FHIR: We work with HL7 International on FHIR standards
• Workgroup for Electronic Data Interchange (WEDI): We work with this organization per a HIPAA statute
• Health Tech Ecosystem

4. Prescription Drugs: Ask your EHR vendor if it supports electronic prior authorization for Part D prescription drugs.