Interoperability and Prior Authorization Rule Summary

Reimbursement; CMS; Medicaid

​In December 2022, the Centers for Medicare & Medicaid Services (CMS) finalized the Interoperability and Prior Authorization Rule (CMS-0057-F). The rule aims to enhance the efficiency and transparency of patient data exchange and establishes. It mandates that impacted payers – including Medicare Advantage organizations, state Medicaid FFS programs, state CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on the FFEs – must implement standardized Application Programming Interfaces (APIs) by January 1, 2027. These APIs will revolutionize how patients, providers, and payers interact with health care data and are positioned to improve care coordination. 

In addition, the rule addresses the prior authorization process. Establishing specific requirements for streamlining these procedures, the rule aims to reduce administrative burdens and improve the timeliness of care delivery. These efforts are particularly relevant for our sector, where timely access to services and interventions can significantly influence patient outcomes and operational efficiency. 
AHCA/NCAL has developed a members-only summary​ for reference.