Unlocking healthcare opportunities through the CMS Interoperability and Prior Authorization Final Rule

Exchanging healthcare information just got easier

As a physician, I know how vital it is for prior authorization determinations to be made quickly. I’m happy to report that major advances are happening right now that will yield better experiences for both patients and providers.

In January 2024, the Centers for Medicare & Medicaid Services (CMS) released the Interoperability and Prior Authorization Final Rule (CMS-0057-F). For some time, prior authorization, access to electronic medical records (EMR), and fragmented health information have been pain points for everyone in healthcare. If left unaddressed, these challenges will not only compound the current lack of transparency we experience today, but they will also result in added costs and unnecessary care.

As a patient-first organization, we’re driven to advance the delivery of evidence-based, connected care to achieve affordable, whole-person health. We support the provisions of CMS-0057-F and recognize that a more efficient prior authorization process benefits everyone and prioritizes provider-patient relationships.

A 360º view of patient health

Limitations on access to information have been an ongoing challenge across the entire healthcare industry. Often, a member’s healthcare information, including data pertaining to prior authorizations, is siloed and only available to their current provider and health plan. If a member’s insurance coverage changes, when switching jobs for example, prior authorization history may not be readily available to their new health plan or provider — or to the member themselves.

CMS-0057-F represents the next chapter in an evolving information landscape that began with the implementation of EMRs. The new rule requires payers, providers, and entities such as Medicare Advantage and state Medicaid programs to use Fast Healthcare Interoperability Resources (FHIR)-based Application Programming Interfaces (APIs) to access health records, facilitate speedier access to data, and share patient data securely within existing HIPAA mandates. The new requirements will improve the exchange of health information between providers, payers, and patients, creating a 360º view of members’ care.

Industry leaders in tech-enabled prior authorizations

At Carelon, we have already built a solid reputation as a pioneer in using technology to improve prior authorizations. In 2004, we implemented the industry’s first online provider portal for prior authorizations. The industry quickly followed our lead.

Because of this and other innovations, we are already in compliance with many aspects of the Final Rule. Today, 93% of the requests that we receive are closed within 48 hours.

Our standards-based API was implemented several years ago to give members access to their data and to optimize information flow with health plans. With this infrastructure already in place, we are now working on information exchange between providers and payers.

Better connected care for members —
less administrative work for providers

Faster prior authorization and facilitated information exchanges mean a better care experience and a more complete picture of members’ overall health. If members switch providers — or insurance plans — these new regulations help to ensure that healthcare information is secure and accessible to new providers. Our systems are designed to better serve patients and provide a more seamless transition for those who are already receiving treatment or who have already received approvals for procedures.

Key components

CMS-0057-F streamlines prior authorization by:

• Reducing decision times: For standard requests, the decision timeframe is seven calendar days. Expedited requests are handled within 72 hours.
• Facilitating access to relevant patient data: Providers can access the information they need within one business day. This includes claims, clinical details, and prior authorization data.
• Streamlining payer-to-payer data exchange: To promote care coordination, payers will transfer health data when members transition between insurance plans through secure, FHIR-based APIs.
• Increasing transparency: Payers will publicly report prior authorization metrics annually, which enhances transparency and facilitates informed decision making.

Our commitment to you

The CMS Interoperability and Prior Authorization Final Rule supports our efforts to simplify how healthcare information and prior authorization data is shared across a member’s healthcare journey. With the changes outlined in CMS-0057-F, we are paving the way for more seamless, connected care.

Member, provider, and health plan benefits

• Faster access to care and a more seamless experience for members
• Less administrative work for providers and more time with patients
• More appropriate care and improved cost trend

Learn more about Carelon Medical Benefits Management or contact us.