Under the CMS Interoperability and Prior Authorization Final Rule, government-regulated payers will be required to implement new electronic data-sharing capabilities by January 2027. Impacted payers include Medicare Advantage plans, State Medicaid and CHIP fee-for-service programs, Medicaid and CHIP managed care plans, and qualified health plans operating on federal health insurance exchanges. While the technology will be implemented by health plans, allergy practices will have to work with their EHR and practice management vendors if they want to connect to—and benefit from—these new capabilities.
The tools are designed to make it easier for physician practices to:
- Obtain prior authorization information electronically.
- Access patient coverage and claims information.
- Reduce manual work, phone calls, faxes, and portal usage.
- Improve care coordination and patient access to information.
Traditional Medicare and commercial insurance plans are not covered by this rule. Several commercial payers have committed to making progress in electronic prior authorization and data-sharing, however.
What does this mean for your practice?
Think of these new requirements as a way to create more direct electronic communication between your practice and payers—and reduce staff time doing manual work.
Today, many staff members spend significant time checking benefits, determining prior authorization requirements, gathering documentation, tracking authorization status and logging into multiple payer portals.
The new payer tools are intended to move more of this work into existing practice systems and automate parts of the process.
“I plan to reach out to our EHR vendor and tell them we would like to understand how our EHR/practice management system will support the new payer application programming interfaces (APIs) and electronic prior authorization capabilities,” said Jean Owen, MBA, vice-chair of the Practice Management Committee. “I encourage other practices to do the same to take advantage of these new requirements.”
New payer capabilities coming by January 2027
Health plans will be required to offer the following new electronic tools designed to make information sharing and prior authorization more efficient for practices.
- Electronic prior authorization: Enables practices to electronically check requirements, submit requests, send supporting documentation, and receive authorization decisions and status updates.
- Clinician access to payer data: Gives clinicians access to certain patient claims, plus clinical and prior authorization information to support care coordination and reduce information gaps.
- Payer-to-payer data exchange: Allows health plans to transfer patient information when members switch plans, helping maintain continuity of information.
- Enhanced patient access: Allows patients to electronically access their claims, coverage, and prior authorization information, improving transparency and engagement.
These new capabilities are intended to provide faster access to payer information, improve care coordination, and support more efficient workflows within clinical practices. However, it will take time for the full benefits to be realized. Payer portals may continue to exist, and phone and fax processes may still be needed in some situations. Benefits will really depend on individual payer readiness and practice workflow integration.
Practice to-do list
To maximize the benefits of the new payer capabilities, allergy practices should begin planning now.
- Assess your current state by identifying key payers, prior authorization volume, and existing workflow challenges.
- Engage with payers to understand their implementation timelines and available support resources.
- Work with your EHR and practice management vendors to determine readiness, integration plans, potential upgrades, costs, training needs, and ongoing support.
- Review and map current workflows to identify where electronic processes may replace or improve manual steps.
- Plan for staff training as new workflows and tools become available.
- Monitor future MIPS requirements related to electronic prior authorization and interoperability reporting.
The January 2027 payer requirements present a significant opportunity to reduce administrative burden and streamline prior authorizations, but the benefits will not happen automatically. Practices that engage early with payers and technology vendors, prepare staff, and evaluate workflow changes now will be in the best position to improve efficiency, reduce manual work, and enhance the patient experience.
