CMS Finalizes Rule for Interoperability and Prior Authorization

Last week, the Centers for Medicare & Medicaid Services (CMS) finalized a rule that advances federal efforts toward interoperability.  Through this rule, “impacted payers” of health plans designed by CMS – including, but not limited to, state issuers of Medicaid and Children’s Health Insurance Program (CHIP) Fee-for-Service programs, Medicare Advantage organizations, and Qualified Health Plan issuers on Federally Facilitated Exchanges – are required to implement and maintain application programming interfaces.  Also known as APIs, these interfaces are relied on by the federal government to uphold global standards for the electronic exchange of health care information.  Beginning in 2026, impacted payers will also be required to streamline their processes for prior authorization (PA), a common practice of insurance organizations that requires providers to get advanced approval before delivering a service to patients.  They must send authorization to providers within 72 hours for urgent requests, and within seven calendar days for non-urgent requests.  Beginning in 2027, impacted payers must implement an approved application programming interface for prior authorization, where providers can access the list of covered items and services and get support with their requests. Additionally in 2027, hospitals, including Critical Access Hospitals, and Merit-based Incentive Payment System (MIPS) eligible clinicians will have to attest to using this electronic interface to submit PA requests as part of their Medicare Promoting Interoperability Program reporting requirements. While the use of various electronic exchange methods among hospitals and physicians has increased in recent years, the Government Accountability Office (GAO) recently found that use among small and rural hospitals is lower than that of other hospitals.  Federal officials and other stakeholders told GAO that these and other federal provisions could be helpful for small and rural providers because it could make the exchange of data less costly.

Read the full article here.

The post CMS Finalizes Rule for Interoperability and Prior Authorization appeared first on Pennsylvania Office of Rural Health.

Recommend0 recommendationsPublished in My Healthy Pennsylvania, Rural Health PA

Related Articles

5 Essential Frameworks for Preventing Violent Child Death

The U.S. has a violent child death problem. Developing strategies to prevent violent child deaths death from firearms and traffic crashes is a demanding task that requires consideration of numerous upstream, interrelated, and tangential issues. To help safety advocates develop strategies to prevent violent child death, we compiled five frameworks to help: Understand and explain …
The post 5 Essential Frameworks for Preventing Violent Child Death appeared first on Salud America.

What Are the Risk and Protective Factors for Violent Child Death?

Gun violence and traffic crashes may seem like unpredictable events. But they are not random. They are systematic. Data reveal trends and patterns in gun violence and traffic crashes that can help us identify risk factors and protective factors. This is especially important for addressing violent child deaths. So what does the data show? Join …
The post What Are the Risk and Protective Factors for Violent Child Death? appeared first on Salud America.

Millions of Latinos at Risk for Losing Medicaid, CHIP Coverage in 2024 

The time is now to secure medical insurance through Medicaid and the Children’s Health Insurance Program (CHIP).  After three years of automatic renewal because of the COVID-19 pandemic, states went back to screening for eligibility in early 2023.  As a result, an estimated 15 million people, including 4.6 million Latinos, could lose their medical coverage …
The post Millions of Latinos at Risk for Losing Medicaid, CHIP Coverage in 2024  appeared first on Salud America.

Medicare: What Latinos Should Know

Medicare can be a complex topic for anyone.   Getting health insurance coverage through Medicare has many moving parts, from knowing where to start, to searching through plans, to choosing the right plan for you.   Let’s dive into Medicare and a few helpful tips to consider when choosing your plan.   What is Medicare?   Medicare is the …
The post Medicare: What Latinos Should Know appeared first on Salud America.