On December 10, 2020, the Centers for Medicare & Medicaid Services (“CMS”) issued a proposed rule to revise the prior authorization process and to add new requirements for state Medicaid and Children’s Health Insurance Program (“CHIP”) fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan issuers on the Federally-facilitated Exchanges to help improve the exchange of electronic healthcare data.

More specifically, the proposed rule would require these impacted payers to enhance the existing Patient Access application programming interface (“API”) that was finalized in CMS’ first phase of its interoperability rulemaking in May of 2020 (85 Fed. Reg. 25510) and allows patients to access certain patient data information. CMS proposes to enhance the Patient Access API by requiring the use of specific HL7 implementation guides. CMS also proposes to require these impacted payers to create a process to ensure that third-party app developers that request patient data from the Patient Access API are adhering to specified privacy requirements. These payers would also be required to report certain information regarding patient data requests to CMS on a quarterly basis by using the Patient Access API.

The proposed rule would also require these impacted payers to build a Provider Access API by using the Health Level 7 Fast Healthcare Interoperability Resources standard. CMS explains that the proposed Provider Access API would facilitate the exchange of “patient data from payers to providers, including adjudicated claims and encounter data (not including cost information), clinical data as defined in the USCDI [US Core for Data Interoperability version 1], and information related to pending and active prior authorization decisions.”

Finally, the proposed rule would require state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, and CHIP managed care entities to send prior authorization decisions within 72 hours after receiving an urgent request and within 7 calendar days after receiving a standard request.

Comments to the proposed rule must be received by CMS no later than January 4, 2021. For additional information on the proposed rule, a CMS Fact Sheet is available here.