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CMS Advancing Interoperability and Improving Prior Authorization Processes Final Rule (CMS-0057-F)

This rule requires impacted payers (Medicare Advantage, Medicaid, CHIP, and QHP issuers) to implement and maintain specific FHIR-based APIs to improve…

What CMS Advancing Interoperability and Improving Prior Authorization Processes Final Rule (CMS-0057-F) requires

This rule requires impacted payers (Medicare Advantage, Medicaid, CHIP, and QHP issuers) to implement and maintain specific FHIR-based APIs to improve patient data exchange and automate prior authorization processes. Key requirements under 42 CFR § 422.120 mandate the implementation of a Prior Authorization Requirements, Documentation and Decision (PARDD) API and specific decision timeframes by January 1, 2027.

Pillar: Medical & Healthcare · Authority: U.S. Department of Health & Human Services (HHS), Centers for Medicare & Medicaid Services (CMS) · Version: 1.0.0 · Last updated:

Primary source: https://www.federalregister.gov/documents/2024/02/08/2024-01239/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-advancing

SHA-256 integrity: eea5a8f85bc1d7cdec9c085f3f17baa5f942917fad80d822214d94f59d9b3322

Primary Citations — 7 traced to source

  • 42 CFR § 422.119 - Patient Access API
  • 42 CFR § 422.120 - Prior Authorization API (PARDD API)

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