CMS releases proposed rule establishing electronic standards for drug prior authorizations

The Centers for Medicare & Medicaid Services April 10 released a proposed rule that would establish electronic standards for drug prior authorizations. Building on a 2024 final rule establishing prior authorization standards for medical services, today’s rule proposes that payers support application programming interface-driven electronic prior authorization for drugs, make decisions on requests within shortened timeframes, and increase transparency for the prior authorization of drugs. In addition, the rule proposes to replace the current HIPAA prior authorization transaction (X12 278) with the API standards established in these rules.