ONC Issues Request for Information on Electronic Prior Authorization Standards

The Office of the National Coordinator for Health Information Technology (ONC) Jan. 21 issued a request for information (RFI) regarding prior authorization standards, implementation specifications and certification criteria that could be adopted within the ONC Health IT Certification Program. Within the RFI, CMS details the significant administrative burdens associated with many current prior authorization processes, highlights some of the past work in this area, details potential transactional solutions, and seeks public input regarding the proposed processes.

More details on the RFI follow.

BACKGROUND

Prior authorization is a process whereby a provider, on behalf of a patient, requests approval from the patient’s insurer before delivering a treatment or service. Although designed to help ensure patients receive optimal care based on well-established evidence of efficacy and safety, health plan implementation of prior authorization requirements have created delays in care, contributed to clinician burnout and have driven up costs for the health care system.

In 2020, ONC identified many of these challenges with the prior authorization process in its Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health Information Technology (IT) and Electronic Health Records (EHRs), including: (i) difficulty in determining whether an item or service requires prior authorization; (ii) difficulty in determining payer-specific prior authorization requirements for those items and services; (iii) inefficient use of provider and staff time to navigate communications channels such as fax, telephone and various web portals; and (iv) unpredictable and lengthy amounts of time to receive payer decisions.

The ONC Certification Program allows health IT developers to obtain ONC certification for their health IT products by meeting established standards, implementation specifications and certification criteria adopted through rulemaking by the Secretary of Health and Human Services. In the RFI, ONC proposes minimum criteria for certification of prior authorization technology vendors that would enable providers to easily identify which services require prior authorization, populate a prior authorization request form using their EHRs, submit prior authorization requests electronically, and receive a response from the payer in a timely manner. Specifically, the RFI proposes the use of three HL7 FHIR (Fast Healthcare Interoperability Resources) implementation specifications (Da Vinci Coverage Requirements Discovery, Documentation Templates and Coverage Rules, and the Prior Authorization Support transactions) to accomplish these tasks.

REQUEST FOR INFORMATION

ONC seeks public comment on a substantial number of the items discussed, including the utilization of the inclusion of prior authorization technology in ONC Certification, the utilization of the proposed minimum certification criteria, whether the proposed implementation specifications are appropriate and sufficiently mature, and whether other technology standards should be considered instead of the FHIR application programming interface.

NEXT STEPS

Comments on the RFI are due 60 days after its publication in the Federal Register. If you have questions, please contact AHA at 800-424-4301.

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