INTRODUCTION
The Workgroup for Electronic Data Interchange (WEDI) is a multistakeholder, non-profit organization named in HIPAA as an advisor to the U.S. Department of Health and Human Services. This is the second WEDI survey of the industry on implementation of the Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F). To review the results of the first survey click here. WEDI is conducting these surveys to determine how the health care industry is implementing CMS-0057-F. These surveys are developed by our Prior Authorization Subworkgroup with input from our Board of Directors. Results will be used to make recommendations to CMS, inform stakeholders, and assist WEDI in the development of industry guidance and education. Go to www.wedi.org for more information about our organization.
BACKGROUND
CMS published CMS-0057-F Final Rule in the Federal Register on February 8, 2024. The rule enhances certain policies from the CMS Interoperability and Patient Access Final Rule (CMS-9115-F) and adds several new provisions to increase data sharing and reduce overall payer, provider, and patient burden through improvements to prior authorization and data exchange practices. Impacted payers are required to implement the API requirements in this final rule by January 1, 2027. Go to this CMS webpage to learn more about this regulation.
Among many requirements, the final rule includes the following provisions:
CMS published CMS-0057-F Final Rule in the Federal Register on February 8, 2024. The rule enhances certain policies from the CMS Interoperability and Patient Access Final Rule (CMS-9115-F) and adds several new provisions to increase data sharing and reduce overall payer, provider, and patient burden through improvements to prior authorization and data exchange practices. Impacted payers are required to implement the API requirements in this final rule by January 1, 2027. Go to this CMS webpage to learn more about this regulation.
Among many requirements, the final rule includes the following provisions:
Patient Access API
Impacted payers are required to implement an HL7® FHIR® Patient Access API. Information must include claims and encounter data, data elements in the United States Core Data for Interoperability (USCDI), information about prior authorizations (excluding those for drugs), and other data.
Provider Access API
Impacted payers are required to make the following data available via the Provider Access API: individual claims and encounter data (without provider remittances and enrollee cost-sharing information); data classes and data elements in the USCDI; and specified prior authorization information (excluding those for drugs).
Payer-to-Payer API
Impacted payers are required to implement and maintain a Payer-to-Payer API to make available claims and encounter data (excluding provider remittances and enrollee cost-sharing information), data classes and data elements in the USCDI and information about certain prior authorizations (excluding those for drugs).
Prior Authorization API
Impacted payers are required to implement and maintain a Prior Authorization API that is populated with its list of covered items and services, can identify documentation requirements for prior authorization approval, and supports a prior authorization request and response. This Prior Authorization API must also communicate whether the payer approves the prior authorization request (and the date or circumstance under which the authorization ends), denies the prior authorization request (and a specific reason for the denial), or requests more information.