Availity Responds to CMS Interoperability and Prior Authorization Final Rule with Advanced Solutions for Healthcare Interoperability

Availity, the nation’s largest real-time health information network, announced a comprehensive suite of technology solutions and services designed to assist health plans and providers in achieving compliance with the Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F), which was published on January 17, 2024.

"Availity recognizes the importance of this rule in accelerating the adoption of new standards that can reduce burden for both payers and providers," said Susan Bellile, Principal of Interoperability at Availity. "We are committed to leveraging our expertise and technology to support our clients through this transition."

The Final Rule aims to enhance interoperability and streamline the prior authorization process by mandating certain health plans to implement specific Health Level Seven International® (HL7®) Fast Healthcare Interoperability Resources (FHIR®) APIs.

Additionally, the Final Rule includes incentives for clinicians and hospitals to utilize FHIR APIs for future authorization requests, as well as new “process” requirements that apply to all prior authorizations managed by the impacted payers.

Health plan organizations impacted by the Final Rule include Medicare Advantage (MA) organizations, Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) offered on Federally Facilitated Exchanges (FFEs).

Availity's Solutions for Compliance

• Payer-to-Payer Data Exchange. By Jan. 1, 2027, impacted health plans must be able to obtain new member data from a member’s prior health plans no later than one week after the start of the new member’s coverage. Availity’s Payer-to-Payer hub will facilitate the acquisition of data from prior payers, significantly reducing the need for the new payer to establish and maintain point-to-point connections with every prior payer. Testing of the hub is in process with an initial cohort of participating payers.
• Prior Authorization API. The Final Rule requires health plans to support a FHIR API for prior authorization by Jan. 1, 2027. The Final Rule recommends the use of the HL7 Da Vinci Burden Reduction implementation guides—Coverage Requirements Discovery (CRD), Documentation Templates and Rules (DTR), and Prior Authorization Support (PAS)—as part of compliance. Availity’s solution will include all three components—PAS, CRD, and DTR—and leverage the company’s existing authorization capabilities.
• Prior Authorization Processes. By Jan. 1, 2026, health plans are required to expedite response times for all prior authorization requests and include information such as reasons for denials and public reporting of metrics. Leveraging Availity tools, payers can access Availity’s performance dashboards with advanced reporting and extract capabilities. For transactions processed through Availity Essentials™ or Availity’s Gateway, Availity provides metrics on volume, status, expedited requests, and other information in our dashboard or as an extraction.
• MIPS Reporting. The Final Rule requires provider organizations to attest to utilizing a Prior Authorization API to submit at least one authorization request in 2027. Providers will be able to connect to Availity to access the Prior Authorization API for multiple payers.

"We are excited to expand our offerings to include new FHIR-based solutions that will deliver on industry goals for interoperability," added Bellile. "Availity's focus has always been on improving the healthcare experience by facilitating effective and efficient communication between payers and providers. With billions of transactions processed through Availity each year, we are uniquely positioned to support the healthcare industry in best meeting these new requirements."

Health plans and providers interested in learning more about Availity's solutions that can help achieve compliance with the CMS Interoperability and Prior Authorization Final Rule are encouraged to visit Availity’s Payer-to-Payer Exchange website.

About Availity

Availity is the trusted partner for organizations seeking to realize the greatest value from clinical, administrative, and financial data. Positioned at the nexus of provider, health plan, and consumer health information, Availity develops scalable, innovative solutions for healthcare data acquisition, standardization, transparency, automation, and exchange among health plans, providers, and technology partners. As one of the nation's largest health information networks, Availity facilitates billions of clinical, administrative, and financial transactions annually. Our suite of dynamic products, built on a powerful, intelligent platform, enables real-time collaboration for success in a competitive, value-based care environment.

For more information, including an online demonstration, please visit www.availity.com or call 1.800.AVAILITY (282.4548). Follow us on LinkedIn and X.

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