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ONC, CMS Partner on Proposed Rules for HIE Interoperability

In December 2022, CMS proposed two rules that aim to align data standards across payers and healthcare providers to streamline HIE interoperability.

Two new proposed rules from The Centers for Medicare & Medicaid Services (CMS) aim to advance health information exchange (HIE) interoperability and streamline prior authorization processes.

The proposed rules reflect collaboration between CMS and ONC to ensure that providers and payers adopt open-industry standards to advance interoperability, according to a HealthITBuzz blog post.

CMS’s Advancing Interoperability and Improving Prior Authorization Processes proposed rule, published on December 13, builds on its 2020 Patient Access and Interoperability rule.

The proposed rule adds new requirements for payers regulated by CMS. If finalized, the proposed law would require healthcare payers to:

  • Establish application programming interfaces (APIs) to share information with healthcare providers about patients covered under the plan
  • Share information with other payers when patients change plans
  • Allow providers to easily obtain coverage requirements for items and services that require prior authorization
  • Submit information needed to request authorization

The rule proposes requiring payers to use the HL7 Fast Healthcare Interoperability Resources (FHIR) standard for these APIs and other interoperability standards referenced in ONC’s Health IT Certification Program and CMS’ Patient Access and Interoperability final rule.

The data set that CMS would require payers to make available through these APIs also builds on the data and associated standards identified in ONC’s United States Core Data for Interoperability (USCDI).

“These are important steps to advance an API ecosystem based on open-industry standards across the healthcare value chain,” ONC official Alex Baker wrote in the blog post.

CMS’s proposed rule includes additional proposals to create incentives for clinicians and hospitals to engage in electronic prior authorization using certified health IT through new measures in the Promoting Interoperability programs.

“As noted in the proposed rule, CMS and ONC are collaborating closely on how certified health IT can support prior authorization activities to lower administrative costs on providers and payers and ensure that patients get the care they need when they need it,” Baker wrote.

The public can submit comments on CMS’ proposed rule through March 13, 2023.

The second proposed rule aims to update ePrescribing standards for sharing information among prescribers, dispensers, intermediaries, and Medicare prescription drug plans.

“CMS and ONC have taken a small but important step in this rule to reduce regulatory burden and ensure consistency across Federal programs,” Baker wrote.

“Historically, our agencies have adopted the same pharmacy standards but in separate rules, an approach that makes it hard for industry to track and which can lead to regulatory misalignment if different agencies update their standards on different schedules,” he noted.

CMS and ONC partenered on a new standards adoption approach to address this.

ONC proposed to adopt a new version of the National Council for Prescription Drug Plans (NCPDP) standard for ePrescribing, which CMS has cross-referenced in proposed updates to standards requirements for the Medicare Part D Prescription Drug program.

In the same rule, ONC proposed to adopt, and CMS proposed to cross-reference, another NCPDP standard that supports Part D requirements for plans to establish real-time benefit tools.

“While ONC did not propose any changes related to electronic prescribing and real-time benefit capabilities under the ONC Health IT Certification Program in this proposed rule, ONC will seek to align with these standards under any future proposals,” Baker wrote.

“We believe the use of common health IT standards across Federal agencies reflected in these rules advances HHS-wide goals for enhanced interoperability to drive innovation and achieve better outcomes,” he added. “We encourage readers to explore these proposals in greater detail.”

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