Interoperability and Prior Authorization Rule Workgroup: Background Material

The Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization final rule establishes new prior authorization requirements that apply broadly to “items and services” other than drugs. State Medicaid and CHIP programs and managed care plans must meet prior authorization policy requirements by 2026 and must implement new application programming interface (API) technologies by 2027. This background material summarizes the rule’s policy and technology requirements, with links to applicable sections of the Code of Federal Regulations for Medicaid and CHIP fee-for-service programs and managed care entities.

This background material was prepared for a Medicaid Evidence-based Decisions Project (MED) workgroup. MED is a collaboration of state Medicaid agencies giving state policymakers the resources they need to make the best evidence-based decisions for improving health outcomes. If you are with a state Medicaid agency and you are interested in other MED workgroup materials, please contact med@ohsu.edu.