CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Authorization Process

On January 17, the Centers for Medicare & Medicaid Services (CMS) released the “CMS Interoperability and Prior Authorization Final Rule” (CMS-0057-F) to improve the electronic exchange of health information and prior authorization process for medical items and services. The final rule applies to Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) Fee-for-Service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs). This final rule establishes requirements for certain payers to streamline the prior authorization process generally starting January 2026 and complements the Medicare...