Standards for Interoperability APIs
CMS proposes to cross-reference versions of the required standards adopted by the Secretary in 45 CFR 170.215. This would allow industry to move to newer versions of the required standards (see the 2024 final rule fact sheet for a list of required standards), as adopted by ONC, rather than necessitating additional CMS rulemaking. In addition, impacted payers would have the flexibility to use updated versions of the required standards under the following conditions: (1) the updated version of the standard is required by other applicable law or the updated version of the standard is not prohibited under other applicable law, (2) the National Coordinator has approved the updated version for use in the ONC Health IT Certification Program, and (3) the updated version does not disrupt an end user’s ability to access the data required to be available through the API.
In addition, building upon the 2024 final rule and in conjunction with the ONC proposals, CMS is proposing to require impacted payers to use a set of currently recommended IGs, as applicable to each of the interoperability APIs. Impacted payers’ interoperability APIs would be required to conform with the proposed, additional IGs beginning October 1, 2027.
Prior Authorization Timeframes
Prior Authorizations for Drugs
To ensure prompt notification and align prior authorization decision processes across different CMS programs, CMS proposes that certain payers be required to provide notice of drug-related prior authorization decisions within specific timeframes.
- To align patient protections and create consistent requirements across the Medicaid and CHIP programs, state Medicaid FFS programs, Medicaid managed care plans, and CHIP managed care entities would be required to make prior authorization decisions for all drugs within a timeframe that aligns with existing decision timeframe requirements for covered outpatient drugs (no later than 24 hours after receiving a prior authorization request) or items and services (seven days for standard requests, 72 hours for expedited requests).
- State CHIP FFS programs would be required to provide notice of a prior authorization decision no later than 24 hours after receiving a prior authorization request for any prescription drugs for which Federal Financial Participation (FFP) is available.
- QHP issuers on the FFEs would be required to provide notice of a prior authorization decision to the requesting provider as expeditiously as the enrollee’s health condition requires, but no later than 72 hours after standard prior authorization requests and no later than 24 hours for expedited prior authorization requests for all drugs.
CMS proposes compliance dates beginning October 1, 2027 for these decision timeframe proposals. Shortening and aligning decision timeframes for prior authorization across CMS programs could improve timely access to medications, which is essential for maintaining health and preventing complications in these populations.
Prior Authorization for Non-Drug Items and Services
Under this proposed rule, CMS is proposing that beginning October 1, 2027, QHP issuers on the FFEs be required to provide notice of prior authorization decisions to the requesting provider for non-drug items and services as expeditiously as the enrollee’s health condition requires, but no later than seven calendar days after receiving a standard prior authorization request and no later than 72 hours after receiving an expedited prior authorization request. This proposal would align prior authorization decision timeframe requirements for QHP issuers on the FFEs with those that finalized for other impacted payers under the 2024 final rule and should mitigate administrative burden with consistent requirements across impacted payers.
Communication of Denials for Drugs
CMS proposes that beginning October 1, 2027, state Medicaid and CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on the FFEs be required to provide providers with a specific reason for denying prior authorization requests for any drugs. These proposals would improve communication between payers and providers when a prior authorization request is denied, align prior authorization requirements across payers, and support providers by giving them the information they need to resubmit or appeal prior authorization denials.
Prior Authorization Metrics
New and Updated Prior Authorization Metrics for Non-Drug Items and Services
The 2024 final rule requires that impacted payers annually report prior authorization metrics for non-drug items and services on their public websites. CMS is proposing to add requirements for impacted payers to report the numeric counts in addition to percentages for certain existing metrics, as well as for impacted payers to publicly report additional prior authorization metrics on non-drug items and services. These proposed requirements would begin on the effective date of the final rule.
The proposed reporting deadlines vary by payer type:
- MA organizations, state Medicaid and CHIP FFS programs, and QHP issuers on the FFEs would be required to report by March 31 of the following year.
- Medicaid managed care plans and CHIP managed care entities would be required to report no later than 90 days after the end of each rating period.
See the proposed rule for more information on new metrics proposed as well as proposed updates to current metrics.
CMS is also proposing that Medicaid managed care plans and CHIP managed care entities report prior authorization metrics for non-drug items and services finalized in the 2024 final rule, as well as prior authorization metrics for non-drug items and services introduced in this proposed rule at both the program and plan levels.
Other impacted payers’ reporting levels would not change:
- MA organizations would still report at the MA contract level,
- State Medicaid and CHIP FFS programs would still report at the state level, and
- QHP issuers on the FFEs would still report at the issuer level.
New Prior Authorization Metrics for Drugs
In addition, CMS proposes to require impacted payers to annually report prior authorization metrics for drugs on their public websites. The proposed compliance dates for reporting these new metrics are in 2028 for data from the 2027 reporting period, with specific deadlines and reporting level varying by payer type, as described in the “New and Updated Prior Authorization Decision Metrics for Non-Drug Items and Services” section above. See section II.C.7. of the proposed rule for more information on the specific metrics proposed for impacted payers.
Publicly reporting these data would provide transparency and accountability in payer prior authorization processes across drugs and non-drug items and services. The additional metrics for non-drug items and services would provide context that would make existing metrics both more complete, as well as useful to the public. Making these data available should build trust with patients and providers and showcase commitment to improving services.
There are many more provisions found in the proposed rule. To view the CMS fact sheet, please go to the following link: 2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule | CMS.