On December 10th, CMS released a proposed rule, building on the CMS Interoperability and Patient Access final rule (CMS-9115-F) that would require certain CMS-regulated payers to improve the electronic exchange of health care data via Application Program Interfaces (APIs) and streamline the prior authorization process to reduce burden on payers, providers, and patients. This proposed rule would place new requirements on Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs, and Qualified Health Plans (QHP) issuers on the Federally-facilitated Exchanges (FFEs).
For a summary of the proposed rule see the CMS Fact Sheet. The proposed rule can be found here: https://www.cms.gov/files/document/121020-reducing-provider-and-patient-burden-cms-9123-p.pdf. The comment period closes on January 4, 2021.
Highlights of the NPRM include that starting January 1, 2023 payers:
- Add prior authorization decisions to Patient Access API information sharing requirements
- Implement a privacy policy attestation process for third-party app developers
- Implement a Provider Access API for payer-to-provider data sharing
- Reduce prior authorization burden on providers through the implementation of APIs and other requirements
- Meet additional Payer-to-Payer requirements, including the use of a FHIR-based API similar to Patient Access
- Add claims, encounters, and prior authorization decisions to Payer-to-Payer Exchange information sharing requirements
- Adopt specified implementation guides to support API implementation
The NPRM also includes five Requests for Information (RFIs). CMS is seeking comments on the following:
- Methods for Enabling Patients and Providers to Control Sharing of Health Information
- Electronic Exchange of Behavioral Health Information
- Reducing Burden and Improving Electronic Information Exchange of Documentation and Prior Authorization
- Reducing the Use of Fax Machines for Health Care Data Exchange
- Accelerating the Adoption of Standards Related to Social Risk Data