Electronic Prior Authorization Increases Efficiency for Community Health Centers

Community Health Centers will be relieved to know that they can now cut down on the cumbersome process related to prior authorization and improve patients' access to timely care. On January 17, 2024, the Centers for Medicare & Medicaid Services (CMS) released the CMS Interoperability and Prior Authorization final rule, which reduces patient, provider, and payer burden by streamlining prior authorization processes and moving the industry toward electronic prior authorization. The CMS rule updates requirements for the previously established Patient Access application programming interfaces (APIs) and establishes three new required APIs: a Provider Access API, a Payer-to-Payer API, and a Prior Authorization API.

While health center partners should have gained access to these APIs by December 31, 2022, some health centers still do not have full access to this functionality. This blog will help you understand some of the benefits of implementing and using the APIs, as NACHC continues to work with Community Health Centers to understand the evolving landscape.

Below is an overview of the final rule as it applies to health centers.

Patient Access API

Under the new rule, Impacted Payers, including Medicare Advantage organizations, state Medicaid and CHIP Fee-for-Service programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) on the Federally Facilitated Exchanges (FFEs), are required to maintain a Patient Access API, effective January 1, 2027. This platform enables Impacted Payers to share information about patients' prior authorization requests and decisions, excluding drug-related requests. Patients can access this information throughout the authorization period and for at least one year after the last status change, improving transparency and engagement.

Impacted Payers must also report specific Patient Access API metrics annually starting January 1, 2026. While a positive step, NACHC and other organizations continue to advocate for CMS to broaden API functionality for vendors, including prescription drugs in prior authorization requirements, and incorporating out-of-network providers.

Provider Access API

Effective January 1, 2027, the new rule also mandates Impacted Payers to implement a Provider Access API to share patient data with in-network providers, enhancing care coordination. However, given varying network adequacy standards, these changes do not consider health center patients needing care from out-of-network providers. Medicaid Managed Care plans have broad discretion for measuring provider network adequacy, and for Medicaid patients, the nearest provider may not be in-network. Under the Affordable Care Act (ACA), qualified health plans are required to meet the essential community provider (ECP) standard, this includes health centers as essential community providers. Despite this requirement, health centers often experience network adequacy challenges due to not being included in certain payers' networks. These network adequacy issues stem from there being no consistent definition of adequacy. For this reason, NACHC encourages CMS to extend the Provider Access API to out-of-network providers to ensure comprehensive patient care regardless of network status.

Additionally, the rule requires Impacted Payers to establish an attribution process for patients and specific providers. CMS's encouragement of health centers to participate in value-based care (VBC) arrangements raises concerns about patient attribution accuracy. Aligning patient attribution requirements among the same payer is crucial to reducing provider burden.

On the bright side, Impacted Payers must provide educational resources to patients about the Provider Access API, emphasizing the right to opt-out of health information sharing.

Prior Authorization API

Some health centers have reported a surge in prior authorizations for imaging and behavioral health services. However, due to the significant variability between health plans' prior authorization service lists and approval criteria, health center providers are often uncertain whether a particular recommended treatment requires prior authorization and, if so, which documents are required for approval. This has led to extensive back and forth between providers and plans, which ultimately has resulted in delayed care.

To alleviate this burden, the CMS rule requires Impacted Payers to implement a Prior Authorization API. This API populates a list of items and services requiring prior authorization, specifies documentation requirements, and supports the creation and exchange of prior authorization requests and responses. This API will significantly reduce delays in patient care by improving efficiency.

Additionally, beginning in 2026, Impacted Payers must notify providers and patients of prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests, enhancing timeliness standards. Unfortunately, these standards do not apply to QHPs on the FFEs.

However, notably, Impacted Payers must provide specific reasons for denials within the outlined decision timeframes, promoting transparency and aiding in the appeal process. This ensures patients and providers understand the rationale behind denials.

A big transition for health centers

NACHC appreciates the time for implementation as this will be a big transition for health centers. For more information, please review this factsheet on the CMS prior authorization rule and background on prior authorization and the history of the push for digitization . If you have any questions, please email [email protected].

Filed under topic(s): Data Governance, Electronic Health Records

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