CMS Final Rule
Mar 13th 2024

Poised and Ready for CMS Prior Authorization Requirements

EviCore by Evernorth is well positioned to meet the Centers for Medicare & Medicaid Services prior authorization requirements.

Years of enhancements have streamlined processes for providers, patients.

The Centers for Medicare & Medicaid Services (CMS) recently released its Advancing Interoperability and Improving Prior Authorization Processes final rule. We sat down with Chief Medical Officer Eric Gratias, M.D., to talk about how well prepared EviCore by Evernorth® is for the rule and what it means for patients, providers and payers.

Would you start by telling us what this rule is meant to do?

With this rule, CMS set out to help streamline prior authorization processes. That’s a goal we certainly share and have been working toward for many years. The interoperability piece of the rule involves the ability of computer systems to exchange and appropriately use data. It’s critical because that data—and the terminology we use around it—is the foundation for everything we do in patient care. If stakeholders use different languages and terminology in their systems, it makes it more difficult and burdensome to get things done and ensure patients get affordable care in the right place at the right time. We were also pleased to see providers included in the rule because it takes all our systems working together to make an impact.

How well are we prepared to comply with the rule?

Because we’ve been focused on similar goals for a long time, we’re really well positioned to meet these requirements and support our payer partners in their efforts to do the same. Here are just a few examples:

  • Our average turnaround times are already shorter than the requirements specified by the rule. The requirements themselves strike the right balance of ensuring there’s time to collect missing clinical information or have a peer-to-peer discussion with a provider if needed while also ensuring patient care can continue to move forward in a timely manner. 
  • If we find a prior authorization request doesn’t meet evidence-based standards, we’re already providing details about why, citing specific clinical guidelines. Our guidelines are freely accessible to anyone; we’ve long been committed to this level of transparency, which is aligned with the goals of the rule. 
  • In terms of prior authorization application programming interfaces (APIs), we’re already using Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) X12 278 prior authorization transaction standard. Both are allowable under the final rule. 

Can you talk a little bit more about how EviCore got to this point, particularly around innovation? 

EviCore has a long history of working to create more effective, collaborative and transparent prior authorization processes through data, technology and innovative approaches. For example, intelliPath is our internal cloud-based solution that seamlessly connects to data in electronic health records to automate case creation and submission. We’re also collaborating with CodeX, which is working to accelerate adoption of the HL7 FHIR standard to help drive better communication across the health care ecosystem. Specifically, we’ve been working on a radiation oncology–focused pilot to improve cancer care delivery and outcomes. Through these efforts, we’ve helped shape the standard for how prior authorization is implemented before regulatory requirements take effect.

On a separate but related note, CMS recently issued guidance around the use of artificial intelligence (AI) to make coverage decisions. How is EviCore approaching that?

We’re totally aligned with the spirit of this guidance. EviCore only uses AI to facilitate faster approval of cases and improve workflow efficiency. For any other decision, there’s a skilled human being involved. 

Contact us for more information about how we are working to align with CMS requirements—and supporting our partners’ efforts to do the same.