CMS-0057-F: Best-in-class solution for the CMS Interoperability and Prior Authorization Final Rule

Firely helps Payers and Health Plans achieve full compliance with the CMS Interoperability Rule

The CMS-0057-F Interoperability and Prior Authorization Final Rule 

On January 17 2024, CMS released the highly-anticipated Interoperability and Prior Authorization Final Rule (CMS-0057-F), a comprehensive initiative aimed at transforming data exchange in the healthcare ecosystem.

Compliance with this new rule requires – among other things – extensive implementation of FHIR via a set of APIs designed to improve access to health information and streamline the prior authorization process. Keeping on top of every development is time-intensive and complicated. With the first deadline less than two years away, it’s time to start thinking seriously about how to implement the requirements.

CMS Interoperability and Patient Access Rule

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The scale of the task

CMS-0057-F is a pivotal regulatory ruling that aims to advance interoperability, patient access, and innovation in the healthcare industry, while also improving the quality and cost-effectiveness of care through seamless data exchange across the healthcare ecosystem.

Access to Prior Authorization

The rule includes changes designed to improve prior authorization processes to help ensure that patients remain at the center of their own care and they get the health care that they need within minutes instead of days. 

Exchange of health information

The rule requires health plans to exchange certain types of health information, such as claims data and encounter data, with other health plans and with patients through APIs.

Timeframe

Some operational provisions take effect as soon as January 2026, while API software will need to be developed and deployed by 1 January 2027.

Healthcare providers

The main focus is on payers but clinicians and hospitals will be impacted by FHIR API reporting obligations, particularly concerning FHIR API prior authorization obligations.

Important interoperability impacts

The CMS-0057-F Rule consists of several important interoperability impacts, including:

Patient API

Patient Access API

The Patient Access API is a policy that requires Medicare Advantage, Medicaid, and CHIP plans to provide their beneficiaries with access to their claims and encounter data through a standards-based API. The API enables beneficiaries to access and share their health information with third-party applications of their choice.

Provider Access API

The Provider Access API requires payers to build and maintain a Provider Access API to share patient data with in-network providers with whom the patient has a treatment relationship. The Provider Access API allows third-party software applications to connect to and access data from an EHR system using FHIR standards.

Data access
Authorization

Prior Authorization Requirements, Documentation, and Decision (PARDD) API

This policy requires Medicaid, CHIP, and certain types of private health plans to make their prior authorization processes electronic and to offer a standards-based API to providers and patients for submitting and receiving prior authorization requests and decisions.

Provider Directory API

The Provider Directory API is a policy that requires Medicare Advantage, Medicaid, and CHIP plans to make provider directory information available through a standards-based API. The API enables beneficiaries to find and select healthcare providers based on location, specialty, and other criteria.

Firely Server illustration
Data exchange

Payer-to-Payer Data Exchange

The Payer-to-Payer Data Exchange policy requires Medicare Advantage, Medicaid, and CHIP plans to exchange certain types of health information, such as claims and encounter data, with other health plans upon beneficiary request. The policy aims to promote care coordination and continuity of care for beneficiaries who switch health plans.

Discover the best in class solution in the market

Built by one of the initiators of FHIR, Firely Server is a FHIR-native plug-and-play solution, that is loosely coupled and fully integrated with your product. It’s fully compliant with the CMS Interoperability and Prior Authorization Final Rule. Expanding the CMS Interoperability and Prior Authorization Final Rule means that our roadmap is constantly kept up to date with the latest regulations and recommended IGs.

Icon Firely Server

Firely Server
ONC compliant FHIR server

Firely Server is our turn-key FHIR server created by one of the initiators of FHIR.
It contains all the features you need to be fully CMS compliant.

Firely Auth

Firely Auth is the authentication server that is seemlessly integrated with SMART on FHIR. Firely Auth is specifically configured to speak FHIR.

Bulk data export

With this plugin you can export bulk data in two ways: an asynchronous data export based on the FHIR Bulk Data Access (or “Flat FHIR”) Implementation Guide, or by using the Patient $everything Operation.

SMART on FHIR

This plugin enables authentication based on the SMART on FHIR specification and allows you to integrate Firely Server with your own authentication and authorization system.

Audit Logging

Firely Server can log access through the RESTful API for auditing purposes.

Logo ONC

Firely is certified under the Office of the National Coordinator for Health Information Technology’s (ONC) Health IT Certification Program. For more information go to the Mandatory Disclosures and API Documentation on our website.

Some interesting reads

Evaluating Firely Server is quick and easy. Here are the two best ways to check it out.

You’ll obviously want to check out Firely Server before you make a purchase. There are two main ways to do just that, but it’s not always obvious which one to choose. That’s something we wanted to clarify, so this article explains how to evaluate Firely Server – with or without a download.

Illustration of CMS Interoperability rule

CMS-0057-F has landed. But what does it mean for your FHIR roadmap?

On 17 January, after months of industry speculation, CMS released the much-anticipated Interoperability and Prior Authorization Final Rule (CMS-0057-F), a comprehensive initiative aimed at reshaping data exchange in the healthcare ecosystem.

How to Build a Dynamic FHIR Implementation Guide

The Simplifier Implementation Guide Editor is the intuitive user interface where you can quickly start creating FHIR Implementation Guides. In recent releases of Simplifier.net we introduced the Firely Query Language (FQL), for dynamic tables of information from your resources, and the feature to create copies of your FHIR Implementation Guides (IG).

Your partner for the CMS Interoperability and Patient Access Rule

Find out how we can help you achieve compliance.
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Rien Wertheim