CMS Interoperability and Prior Authorization Rules Update: Stakeholder Requirements, Timeline, Compliance Challenges

This CLE webinar will examine recent CMS rulemaking focused on improving the electronic exchange of healthcare data and prior authorization practices. The panel will discuss the 2024 CMS Interoperability and Prior Authorization Final Rule which will be fully effective on Jan. 1, 2027, and the 2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule which builds on the 2024 rule. The panel will address stakeholder impact and offer best practices for guiding covered clients through this evolving regulatory landscape.

With the goal of improving the electronic exchange of health information among patients, providers, and payers, as well as prior authorization practices, CMS has published rules in recent years—most notably a final rule in 2024 to be fully effective Jan. 1, 2027, and a proposed rule in 2026 building on the 2024 rule—related to interoperability and prior authorization requirements. Counsel for stakeholders should be up to date on CMS rulemaking in this area so they can best guide their clients on compliance issues.

Key provisions in the 2024 CMS Interoperability and Prior Authorization Final Rule (the 2024 rule) include: (1) updating requirements for the previously established Patient Access API and establishing three new required APIs—Provider Access API, a Payer-to-Payer API, and a Prior Authorization API; (2) outlining new timeframes for prior authorization decisions; (3) requiring impacted payers to provide specific reasons for denials of prior authorization requests within the new timeframes; and (4) creating new reporting requirements for impacted payers related to certain aggregated prior authorization metrics. While certain provisions of the 2024 rule were to already be implemented, the 2024 rule becomes fully effective on Jan. 1, 2027, when impacted payers must meet the API requirements.

Most recently, CMS proposed the 2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule (the 2026 rule) which builds on the 2024 rule and extends many of the prior authorization requirements to pharmaceuticals. Among other things, the 2026 rule proposes to require impacted payers to "support electronic prior authorization, to make decisions on requests within shorter timeframes that align CMS programs, and to increase transparency for the prior authorization of drugs" as well as "to update health information technology (health IT) standards and to report interoperability API endpoints and API usage metrics to CMS."

Listen as our authoritative panel examines recent CMS rulemaking related to health information exchange and prior authorization practices. The panel will address the impact the 2024 and 2026 rules may have on stakeholders and offer best practices for compliance.