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New prior auth rule aims for API adoption, 7-day turn by 2026

As CMS looks to solve yet another one of healthcare’s biggest points of friction, Part B News recently reached out to Moxe’s Founder and CEO, Dan Wilson, to get his take on the new rule that leans into application programming interfaces (APIs) to solve for burdensome prior authorizations.


This new rule expands coverage to Medicare Advantage and builds upon previous interoperability rules issued by CMS and the Office of the National Coordinator (ONC) that propose payers be required to develop application programming interfaces (API) that would let patients know the status of any pending or active prior authorization decisions in a more timely manner (i.e., no later than one business day after a request for a prior authorization is initiated). In reality, most decisions would have a seven day deadline, which is an improvement from the current 14-day deadline. There remains a 72-hour exception for expedited circumstances.


Expediting prior authorizations would certainly make providers and patients happy. But can payers deliver?

According to Dan, “Only a very small amount of the API work is going to be technical work on the APIs themselves,” he says. “The bigger challenge is going to be: How do you use APIs to make authorization determinations, and how do you get all of the business logic consolidated so you can make a determination within the timelines that are outlined in this rule?”


To learn more, read the full article by Roy Edroso in the December 19th edition of Part B News.


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