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U.S. Dept. of Health & Human Services
CMS Interoperability and Patient Access final rule
Guidance for the Interoperability and Patient Access final rule.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: July 17, 2020
Policies and Technology for Interoperability and Burden Reduction
CMS Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (CMS-0057-P)
The CMS Advancing Interoperability and Improving Prior Authorization Processes proposed rule (CMS-0057-P) is now available in the Federal Register and open for public comment. This proposed rule builds on the policies finalized in the CMS Interoperability and Patient Access final rule (CMS-9115-F) published May 2020 and policies introduced in the CMS Interoperability proposed rule (CMS-9123-P) published December 2020, which we are withdrawing in this proposed rule. The newly proposed rule considers stakeholder feedback and includes Medicare Advantage plans.
This proposed rule emphasizes the need to improve health information exchange to achieve appropriate and necessary access to complete health records for patients, health care providers, and payers. This proposed rule also focuses on efforts to improve overall prior authorization processes through policies and technology to help ensure that patients remain at the center of their own care.
Proposed Rule Publication
To view the CMS Advancing Interoperability and Improving Prior Authorization Processes proposed rule (CMS-0057-P), visit the Federal Register.
Closed: The Public Comment Period for the Advancing Interoperability and Improving Prior Authorization Processes proposed rule (CMS-0057-P) closed on March 13, 2023
Additional Resources
Read the Fact Sheet to learn more about the CMS Advancing Interoperability and Improving Prior Authorization Processes proposed rule (CMS-0057-P) and the FAQs to learn more about the past CMS Interoperability rules.
Overview
On October 5, 2022, CMS published a request for information soliciting public comments on establishing a National Directory of Healthcare Providers & Services (NDH) that could serve as a "centralized data hub" for healthcare provider, facility, and entity directory information nationwide. The RFI is published in the Federal Register, and the 60 day comment period will end on December 6.
On December 8, 2021, CMS announced the publication of a Federal Register Notice (FRN CMS-9115-N2) to formalize its decision to exercise enforcement discretion not to take action against certain payer-to-payer data exchange provisions of the May 2020 Interoperability and Patient Access final rule (see FAQs associated with this decision). The Administrator also released a blog on this Notice, which included additional information about the administration's commitment to increasing health data exchange and investing in interoperability.
On September 15, 2021, CMS published three FAQs which explain that CMS will not take enforcement action against certain payers for the payer-to-payer data exchange provision of the May 2020 Interoperability and Patient Access final rule until future rulemaking is finalized. CMS’ decision to exercise enforcement discretion for the payer-to-payer policy until future rulemaking occurs does not affect any other existing regulatory requirements and implementation timelines outlined in the final rule. Please review the relevant FAQs for details.
As of July 1, 2021, two of the policies from the May 2020 Interoperability and Patient Access final rule are now in effect. On April 30, 2021, the requirements for hospitals with certain EHR capabilities to send admission, discharge and transfer notifications to other providers went into effect. On July 1, 2021, CMS began to enforce requirements for certain payers to support Patient Access and Provider Directory APIs. Additional information is available on the FAQ page and in the other information available below.
CMS continues to build on its roadmap to improve interoperability and health information access for patients, providers, and payers. When implemented effectively, health information exchange (interoperability) can also reduce the burden of certain administrative processes, such as prior authorization. Our regulations will drive change in how clinical and administrative information is exchanged between payers, providers and patients, and will support more efficient care coordination.
The CMS regulations include policies which require or encourage payers to implement Application Programming Interfaces ( APIs) to improve the electronic exchange of health care data – sharing information with patients or exchanging information between a payer and provider or between two payers. APIs can connect to mobile apps or to a provider electronic health record (EHR) or practice management system to enable a more seamless method of exchanging information. The regulations also include policies which may reduce burdens of the prior authorization process by increasing automation and encouraging improvements in policies and procedures to streamline decision making and communications.
On this page you can find links to resources that will be useful for implementing the APIs to support the policies of these rules. In particular we encourage stakeholders to use the general information for the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) Implementation Guides (IGs) referenced in the CMS regulations.
Quick Links – Can’t wait to find what you are looking for? Skip ahead with these links below:
API Name
Supporting IGs
