top of page

Decoding the Latest CMS Rule on Prior Authorization

Implications of the New CMS Rule

On January 17, 2024, the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) was finalized. The rule is a landmark development in the healthcare sector, with important implications for the prior authorization process. It impacts a wide range of entities, from Medicare Advantage organizations to Medicaid managed care plans, and poses challenges for health plans in terms of compliance and operational efficiency. In this transformative landscape, stands ready to assist health plans in aligning with the new requirements through its innovative AI-driven Prior Authorization (PA) and Utilization Management (UM) platform.

Impact on Payers, Providers, and Members

The new CMS rule, while presenting challenges, also brings opportunities for payers to enhance their operational efficiency. The requirement to implement FHIR APIs by 2027 means significant upgrades to existing IT infrastructure for payers. Such upgrades offer the potential to streamline data management and exchange processes, leading to improved services for members and more affordable care delivery. Additionally, these technological advancements are likely to bolster member retention and engagement by facilitating better data exchange between payers, members, and providers.

Key Changes in the CMS Rule

FHIR API Implementation by 2027: Health plans are required to develop FHIR-based Application Programming Interfaces (APIs) for streamlined data exchange and prior authorization processes.

Transparent Denial Communication by 2026: Health plans are required to provide clear explanations for prior authorization denials to facilitate resubmissions or appeals.

Prior Authorization Metrics Publication by 2026: Health plans are required to publish metrics regarding prior authorization similar to those published by Medicare FFS, including statistics on requests, approvals, appeals, and accuracy.

Shorter Turnaround Times by 2026: Health plans are required to issue decisions for expedited (urgent) requests within a 72-hour timeframe and for standard requests within a seven-day period. This requirement does not apply to qualifying health plans operating on federally-facilitated exchanges.

The Road Ahead

The path forward for health plans in response to the CMS rule encompasses both challenges and strategic opportunities. The necessity to upgrade to FHIR-based APIs by 2027 requires a thoughtful approach to IT infrastructure enhancement, ensuring that systems are not only compliant but also optimized for future scalability and integration.

In addition to technological upgrades, health plans can focus on enhancing data management capabilities. This involves not just the implementation of new software solutions but also a reevaluation of data governance and workflow processes. The aim is to create a more streamlined and efficient system that can handle the increased data flow and communication requirements set by the CMS rule.

How Facilitates Compliance, with its cutting-edge platform, is uniquely positioned to support health plans in this transition. By leveraging generative AI, encodes health plan policies and EHRs into simplified processes, ensuring quick and compliant decision-making.

Reducing Administrative Burden and Supporting Faster Turnaround Times:’s generative AI encodes health plan policies and Electronic Health Records (EHR) into simplified checklists.’s real-time benefit check (RTBC) rules, which automate approval for cases aligning with health plan guidelines, and suggestion of pre-approved, personalized care pathways expedite the time to decision. This approach streamlines workflows, enabling health plans to meet the CMS’s required turnaround times for prior authorization requests.

Enhancing Interoperability:’s platform, compliant with FHIR HL7 and DaVinci protocols, facilitates seamless data exchange. This interoperability ensures that health plans can efficiently collaborate across the healthcare ecosystem.

Ensuring Regulatory Compliance:’s engine instantaneously encodes new regulations, including those outlined in the CMS rule, into PA and UM processes. This feature ensures that health plans can swiftly adapt to federal mandates, maintaining compliance without the need for extensive manual intervention.

Delivering Transparent and Expedited Decisions:’s capacity to automatically provide clear, evidence-based explanations for PA decisions to members and providers aligns with the CMS rule's requirement for transparency.’s automated decision-making process is not only timely but also explains the rationale behind each decision, ensuring compliance with the rule's requirement for clarity in denial communication.

Partnering with can help health plans navigate these new regulations, ensuring they are well-equipped to meet both present and future demands in the healthcare sector.

151 views0 comments


bottom of page