CMS pushes ePA and interoperability
- CMS proposed expanding electronic prior authorization and modernizing HIPAA transaction standards. - The proposal would extend electronic prior authorization (ePA) to drugs and require faster prior‑authorization decisions. - Advocates say the rule could increase transparency and speed for medications, but front-line relief may take time to materialize ( ).
The Centers for Medicare & Medicaid Services has proposed forcing more drug prior authorizations into electronic systems and putting firm clocks on insurer decisions. (cms.gov) CMS released the proposed rule on April 10, 2026, and it was published in the Federal Register on April 14, 2026, with a comment period that runs 60 days from publication. The agency labeled it CMS-0062-P. (cms.gov) (federalregister.gov) The proposal would require affected payers to answer urgent drug prior-authorization requests within 24 hours and standard requests within 72 hours. CMS said the rule would apply to Medicare Advantage organizations, Medicaid and Children’s Health Insurance Program fee-for-service programs and managed care plans, and qualified health plans sold on the federally facilitated exchanges. (cms.gov) (federalregister.gov) Prior authorization is the insurer’s yes-or-no checkpoint before a patient gets some drugs or services paid for. CMS said its 2024 interoperability rule set electronic prior-authorization requirements for many non-drug items and services, and this new proposal extends similar requirements to drugs. (cms.gov) (federalregister.gov) The technical change is about replacing phone calls, faxes, and portal-by-portal forms with standard electronic messages and application programming interfaces, the software connectors that let health plans and clinicians exchange data automatically. CMS said the proposal would require support for electronic prior authorization using the National Council for Prescription Drug Programs SCRIPT standard and would update older Health Insurance Portability and Accountability Act transaction standards. (federalregister.gov) (cms.gov) CMS also proposed more disclosure around denials, approvals, and appeals, including public reporting for some plans. The agency said it wants patients and prescribers to see more clearly how often requests are rejected and how often those decisions are overturned. (cms.gov 1) (cms.gov 2) The rule lands after years of complaints from doctors, hospitals, and patient groups that prior authorization delays care and adds staff work. In a June 2024 pledge organized by the Department of Health and Human Services, major insurers said they would expand real-time responses, standardize electronic submissions, and reduce the volume of services subject to prior authorization by January 1, 2026. (hhs.gov) Drug workflows are harder to change than a rule on paper because prescribers, pharmacies, pharmacy benefit managers, health plans, and electronic health record vendors all use different systems. CMS said in the proposal that commenters on its earlier rule supported electronic prior authorization but also pointed to implementation work across those systems. (federalregister.gov) A separate federal rule already updated retail pharmacy HIPAA transaction standards in December 2024, including the Medicaid pharmacy subrogation transaction. CMS said this new proposal would build on that standards work rather than leave drug prior authorization in older, less connected processes. (federalregister.gov) (cms.gov) What happens next is procedural but important: CMS will take comments, decide what to change, and then issue a final rule with compliance dates. Until then, the proposal sets the direction of travel — faster deadlines, more electronic routing, and fewer drug authorizations handled by fax. (federalregister.gov)
