The Centers for Medicare & Medicaid Services (CMS)recently released the Interoperability and Prior Authorization Final Rule (CMS-057-F), a groundbreaking initiative to enhance healthcare interoperability, streamline prior authorization processes, and reduce administrative burdens. This rule, finalized on January 17, 2024, marks a major step forward in ensuring that patients, providers, and payers can seamlessly exchange health information. Let’s break down the key provisions of these guidelines and explore how Banjo Health is uniquely positioned to help organizations achieve compliance.
Key Provisions of CMS-057 Guidelines
Patient Access API Enhancements
Under CMS-057-F, payers are required to expand their Patient Access APIs to include details about prior authorization requests (excluding drugs). This provision ensures that patients have timely access to their prior authorization status and supporting documentation.
Provider Access API Implementation
CMS mandates payers to establish a Provider Access API that facilitates secure sharing of patient data—including claims, encounters, and USCDI data—within-network providers. Patients retain the option to opt out of data sharing, preserving their privacy.
Payer-to-Payer Data Exchange API
To ensure continuity of care, payers must implement a Payer-to-Payer API for seamless data exchange when patients switch insurers or have overlapping coverage. This ensures payers have access to complete and accurate health records.
Prior Authorization API Improvements
The rule requires payers to provide a dedicated Prior Authorization API to streamline the process. This API must identify prior authorization requirements, support electronic submissions, and adhere to response deadlines: 72 hours for expedited requests and seven calendar days for standard ones. Additionally, payers must provide specific reasons for denials.
Electronic Prior Authorization for Providers
To incentivize the adoption of electronic prior authorization, CMS has added a new measure under the Health Information Exchange (HIE) objective for the Merit-based Incentive Payment System (MIPS) and the Medicare Promoting Interoperability Program.
How Banjo Health Helps You Stay Ahead
At Banjo Health, we understand the complexities of navigating regulatory requirements like CMS-057-F. Our AI-powered solutions are designed to streamline compliance and improve operational efficiency for payers and providers alike. Here’s how we address the new guidelines:
Seamless API Integration
Our platform enables seamless integration with Patient Access, Provider Access, and Payer-to-Payer APIs, ensuring compliance with interoperability requirements while enhancing data exchange capabilities.
Automated Prior Authorization
Banjo Health’s proprietary AI models expedite prior authorization workflows by automating submissions, ensuring adherence to CMS-mandated timelines, and reducing administrative burdens. With real-time status updates and automated denial explanations, our system aligns perfectly with the Prior Authorization API improvements.
Enhanced Patient and Provider Experience
By offering a unified, intuitive platform, we simplify the data-sharing process or providers while empowering patients with greater transparency into their healthcare journeys.
Robust Security and Compliance
As a HITRUST r2-certified organization, Banjo Health prioritizes the security of patient health information, ensuring your organization meets CMS’s high standards for data protection and privacy.
Stay Compliant and Transform Your Workflow with Banjo Health
The CMS-057 guidelines represent a monumental shift in healthcare interoperability and prior authorization processes. At Banjo Health, we’re here to help you navigate this change seamlessly with our cutting-edge, AI-driven solutions.
Ready to see how Banjo Health can revolutionize your prior authorization and interoperability workflows? Visit Banjo Health’s website to learn more.
