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Edifecs

Posted on January 26, 2024 | 3 min read

Preparing for CMS-0057-F Interoperability and Prior Authorization Rule

Categories:

Consumer Experience

Healthcare Data

Regulatory Compliance

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Preparing for CMS-0057-F Interoperability and Prior Authorization Rule

On January 18, CMS announced CMS-0057-F, also known as the Interoperability and Prior Authorization final rule. This rule builds on the Interoperability and Patient Access Final Rule (CMS-9115-F) by updating key provisions and introducing new requirements, including:

  • The inclusion of several new APIs intended to improve and simplify the prior authorization process
  • Updated requirements for Patient Access APIs
  • A new Provider Access API policy
  • Additional requirements for Payer-to-Payer Data Exchange on FHIR®

CMS-0057-F provides healthcare organizations an opportunity, and requirement, to improve the patient experience and dramatically reduce administrative burden related to prior authorization. According to CMS estimates, the implementation of CMS-0057-F will save providers 206 million hours on administrative tasks, which translates to $15 billion in cost savings over the next decade.

What CMS-0057-F Means for Healthcare Organizations and Patients

 

Provision Healthcare Providers Patients Payers
Prior authorization (PA) records must be available via Patient Access API within 1 business day No impact Have access to prior authorization data and can check status Need to submit aggregated, de-identified, annual metrics to CMS
New Provider Access API exposes USCDI and EOB data to new stakeholder Can access administrative and clinical data for their attributed patients / members Consent to what data is shared with whom and for how long Must determine attribution methodology and framework for consent
Payers can exchange member data to understand populations transitioning across coverages No impact Can opt-in to share longitudinal data across payers With patients’ consent, can access clinical records automatically at the time of enrollment.
Simplified administration around the prior authorization process Can implement PA process within the context of existing clinical workflows Receive public reporting on PA approval timeliness across payers Can track and report on key PA metrics & SLAs
Stricter decision data requirements and faster turnaround by payers on authorization requests Receive authorization decisions and rejection details faster Receive authorization sooner, reducing barriers to care (Starting 1/1/2026)
Must process and send decisions within 72 hours for cases seven days for non-urgent cases

 

Budgeting and Timing

Per the final rule, impacted payers are required to implement certain provisions generally by January 1, 2026. To allow time for review, procurement, and implementation of the new provisions, Edifecs recommends organizations consider the following general timeline:

  1. Budgeting, Procurement Planning Approval: By mid 2024
  2. Procurement, Award and Negotiation: Mid 2024 – Early 2025
  3. Implementation: Early 2025 – Late 2025
  4. Go Live – Late 2025

How Edifecs Can Help

To effectively manage data intake, quality, and exchange and meet the reporting requirements of CMS-0057-F, organizations should consider consolidating their operations within a single technology platform. Edifecs is recognized as Best in KLAS for Payer Interoperability and has provided more DaVinci Implementation Guides than any other vendor for the Interoperability and Patient Access Final Rule (CMS-9115-F). The same energy, investment and expertise demonstrated in addressing CMS-9915-F has been applied to CMS-0057-F technology and solutions. We are uniquely positioned to help organizations transform business processes like prior authorization by reducing administrative burdens and applying data exchange standards like Coverage Requirements Discovery (CRD), Documentation Templates and Rule (DTR), and Prior Authorization Support (PAS). In addition to meeting compliance regulations, Edifecs can help holistically address interoperability challenges by:

  1. Fully defining consent, attribution, and digital guidelines that meet stakeholder needs and support the evolution of underlying business processes
  2. Identifying integrations and automation opportunities for forward-looking business processes, such as utilization management and EHR integration
  3. Reviewing data sources in use today and the development tools used to ensure high-quality data exchange and access

In the coming weeks, we will provide more in-depth analysis of the key provisions of CMS-0057-F and what they mean for healthcare organizations. For more information on how Edifecs can help your organization prepare for and adapt to CMS-0057-F, get in touch with our team today.


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