Letter on Notice of Proposed Rule Making Regarding Adoption of Standards for Prior Authorization Attachments

July 26, 2023

The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Hubert H. Humphrey Building, Room 445–G
200 Independence Avenue, SW
Washington, DC 20201

Re: Follow-up on Notice of Proposed Rule Making Regarding Adoption of Standards for Prior Authorization Attachments (CMS-0053-P)

Dear Administrator Brooks-LaSure:

As national organizations representing physicians, hospitals, and health insurance plans, we sincerely appreciate efforts by the Centers for Medicare & Medicaid Services (CMS) to reduce administrative burdens and costs in our health care system through the December 2022 Notice of Proposed Rule Making (NPRM) regarding adoption of electronic transaction standards for health care attachments. We also applaud CMS’ focus on reforming prior authorization (PA) and share the Administration’s goals of ensuring timely access to care for patients and minimizing manual paperwork for all health care stakeholders. However, our organizations urge CMS to not proceed with implementing the PA attachment standards provisions of the NPRM due to conflicting regulatory proposals that would set the stage for multiple PA electronic standards and workflows and create the very same costly burdens that administrative simplification seeks to alleviate.

While the electronic standards proposed in the attachments NPRM align with those recommended by the National Committee on Vital and Health Statistics in 2016, we note that there have been significant developments in both the technology and regulatory spaces in the intervening years. First, major efforts are underway to automate PA-related data exchange leveraging Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) implementation guides. Secondly, and even more significantly, the Advancing Interoperability and Improving Prior Authorization NPRM (CMS-0057-P) would require federally regulated health plans to offer HL7 FHIR-based application programing interfaces to support electronic PA information exchange. In contrast, the attachments NPRM would require a combination of both X12 and HL7 standards and apply to all health plans under the Health Insurance Portability and Accountability Act (HIPAA) regulatory pathway.

We are concerned by the conflicting provisions of these NPRMs that would establish two different sets of standards and corresponding workflows to complete the PA process, depending on the type of health plan. Moreover, for federally regulated plans, this would require cross walking the two standards for no discernable benefit. This outcome would directly counter the foundational principles of the original HIPAA administrative simplification statute and regulations (i.e., adoption of electronic standards to support uniform communication between providers and all health plans); cause widespread industry confusion; and be enormously expensive for both health plans and providers, as they would undoubtedly need to implement technologies to meet the requirements of both NPRMs.

For these reasons, our organizations strongly advise against adoption of standards for PA attachments as proposed in this rule. We sincerely appreciate CMS’ efforts to simplify and streamline the PA process to benefit patients, health care professionals, and health plans and look forward to continuing to work with you in these efforts.

Sincerely,

AHIP
American Hospital Association
American Medical Association
Blue Cross Blue Shield Association