The Prior Authorization Final Rule

What providers need to know.

Prior authorization is a primary source of pain for healthcare providers. It creates significant administrative burdens that increase labor and can lead to delayed patient treatment. In addition, high rates of prior authorization denials can be frustrating and discouraging for providers who are simply trying to provide the best care possible to their patients.

Overall, the process of prior authorization can be a significant barrier to delivering timely and effective healthcare. Therefore, to overcome the prior authorization burden, CMS recently published its Interoperability and Prior Authorization final rule (CMS-0057-F). Although payer requirements begin in 2026, patients and providers will start feeling its effects beginning January 1, 2027.

The rule's finalization marks a pivotal moment in the ongoing effort to streamline healthcare operations, enhance patient access to health information, and reduce administrative burdens on providers.

Here's what providers need to know about the new rule:

Streamlined prior authorizations 

As its name implies, the rule mandates a more streamlined process for prior authorizations via a Provider Access API. Healthcare providers will be able to send prior authorization requests electronically and (theoretically) receive responses faster. This process should reduce administrative burdens significantly for providers, allowing them to focus more on patient care than paperwork. For patients, this means potentially shorter waits for treatment and a more transparent view of their care process.

Improved transparency

It's also worth noting that the rule includes measures to increase the transparency of the prior authorization processes. Payers will be required to publicly report certain metrics related to prior authorization, such as the percentage of requests approved or denied and the average time taken to respond to requests. This transparency is anticipated to increase accountability and incentivize improvements in the prior authorization process over time.

Increased patient access to health information 

One of the most talked-about aspects of this rule is its focus on enhancing patient access to their health information. By requiring payers on the federal exchanges (such as Medicare) to implement and maintain a secure, standards-based API, the rule will provide additional access to health information for patients, including data about prior authorization decisions.

Shared patient data

In the drive towards value-based care, the rule will allow in-network providers with whom the patient has a treatment relationship to access patient clinical information such as claims and encounter data. Patients will be able to opt out of data sharing through their payer.

What will providers need to do?

For healthcare administrators and billers, adapting to this new rule will require updating systems and workflows to comply with the new requirements. This may involve investing in new technology or upgrading existing systems to support the electronic exchange of data and to enable the use of the required APIs. Training staff in new procedures and ensuring compliance with the rule's requirements will also be critical steps.

The new rule will also have an associated MIPS measure titled "Electronic Prior Authorization" under the Promoting Interoperability performance category of MIPS beginning in the 2027 calendar year. The measure will require a yes/no attestation or an applicable exclusion.

The finalization of the Interoperability and Prior Authorization final rule represents a significant step forward in enhancing the efficiency of clinical care. However, prior authorization for drugs will not be included but may be introduced in the future if the rollout of the final rule goes smoothly. While the transition may involve challenges, particularly in adapting to new technologies and processes, the potential improvements in healthcare delivery and patient care will make it worthwhile.

If your organization is looking to navigate the complexities of prior authorization and comply with the new CMS rule, OncoSpark can help. Our AuthParency software provides complete transparency for every prior authorization. We combine that with a team of experts to assist you in optimizing your workflows and improving the overall efficiency of your healthcare operations. Contact us to learn more about how we can support your organization in this transition.