Health plans covered by a federal interoperability rule must begin processing prior authorization requests electronically Jan. 1, but the rule’s reach into ASCs may be limited. It excludes many of the payers ASCs depend on most, and the systems that connect ASCs to it may not be ready, Medical Economics reported Oct. 12.
The rule, CMS-0057-F, requires covered plans to run standardized electronic connections that transmit prior authorization requests, documentation and decisions between a physician’s EHR and the plan.
Which payers are covered
The rule applies to Medicare Advantage plans, state Medicaid and Children’s Health Insurance Program fee-for-service programs, Medicaid and CHIP managed care plans, and marketplace plans sold on the federal exchange.
It does not apply to employer-sponsored commercial plans or traditional Medicare. Commercial payers are typically ASCs’ largest source of revenue, so many surgical authorizations will continue to move by fax, portal and phone after Jan. 1.
Medicare Advantage is where ASCs are most likely to notice a change, since those plans already require prior authorization for many surgical procedures.
Who submits the request
The rule regulates health plans, not providers. The provider side of each connection is whatever EHR, prior authorization tool or billing partner submits the request, and if those vendors are not ready, the plan can report compliance in January while the practice keeps faxing.
For many ASC cases, the surgeon’s practice submits the authorization request, not the ASC. Whether the electronic decision reaches the surgery center’s own scheduling and billing systems, or staff still call to confirm, will depend on how those systems connect.
The American Medical Association has raised concerns about vendor readiness. In September, AMA CEO John Whyte, MD, urged CMS to keep the Jan. 1 date and not give plans broad leeway on enforcement in 2027, noting that much of the implementation work falls to vendors that CMS does not oversee.
Drugs are excluded
The rule excludes prior authorization for drugs, including drugs administered in the office and billed to the medical benefit. That leaves out injectables common in pain management, ophthalmology and GI centers.
A separate CMS proposal issued in April would bring medical-benefit drugs into the electronic prior authorization system starting Oct. 1, 2027. The comment period closed June 15, and there is no final rule yet.
What has already changed
Some parts of the rule took effect earlier this year. Since Jan. 1, covered plans must decide standard prior authorization requests within seven calendar days and urgent requests within 72 hours, must give a specific reason for any denial, and have to post their prior authorization statistics publicly for the first time by March 31.
The electronic system won’t necessarily make decisions faster. Plans may still route a request for clinical review within the seven-day or 72-hour window. Fax isn’t going away either: plans must add the electronic channel but do not have to close the old ones.
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