Data Strategy Briefing — January 17, 2024
CMS finalised interoperability and prior authorization reforms that require payers to stand up new APIs, faster decisions, and public reporting between 2026 and 2027.
Executive briefing: The Centers for Medicare & Medicaid Services (CMS) issued its Interoperability and Prior Authorization final rule (CMS-0057-F) on 17 January 2024, mandating standardised FHIR APIs, 72-hour urgent prior authorization decisions, and annual metrics reporting for affected payers.
Key data governance checkpoints
- API roadmap. Implement Patient Access, Provider Access, Prior Authorization, and Payer-to-Payer APIs that meet HL7 FHIR standards and security controls by 2026–2027 compliance dates.
- Decision tracking. Automate prior authorization workflows to deliver 72-hour urgent and 7-day standard determinations with auditable data trails.
- Public metrics. Prepare to publish quarterly denial rates, turnaround times, and appeal outcomes beginning with the 2026 reporting cycle.
Operational priorities
- Systems integration. Align utilisation management, claims, and member portals with the new API infrastructure and documentation exchange requirements.
- Policy updates. Refresh provider manuals and member communications to reflect automated prior authorization pathways and data-sharing rights.
- Vendor oversight. Evaluate interoperability vendors on FHIR implementation guides, OAuth 2.0 security, and uptime SLAs.
Enablement moves
- Launch cross-functional steering groups spanning clinical, IT, legal, and operations to oversee compliance milestones.
- Develop analytics dashboards that monitor API transaction volumes, prior authorization cycle times, and denial reasons.
Sources
- CMS press release on the Interoperability and Prior Authorization final rule
- Federal Register text for the CMS-0057-F final rule
Zeph Tech equips payers and health systems with implementation plans covering prior authorization APIs, decision automation, and regulatory reporting.