ONC Seeks Public Comment on Electronic Prior Authorization Standards, Implementation Specifications and Certification Criteria

The U.S. Department of Health and Human Services’ (HHS) Office of the National Coordinator for Health Information Technology (ONC) today released a Request for Information (RFI) seeking input from the public on electronic prior authorization standards, implementation specifications and certification criteria that could be adopted within the ONC Health IT Certification Program (Certification Program). Responses to this RFI may be used to inform potential future rulemaking to better enable providers to interact with health care plans and other payers for the automated, electronic completion of prior authorization tasks. Ultimately, such electronic processes will serve to ease the burden of prior authorization tasks on patients, providers, and payers.

Prior authorization requirements are established by payers to help control costs and ensure payment accuracy by verifying that an item or service is medically necessary, meets coverage criteria, and is consistent with standards of care. However, stakeholders have frequently noted that the processes associated with satisfying these requirements result in administrative burden for patients, health care providers, and payers. Diverse payer policies, workflow challenges, and technical barriers around prior authorization processes contribute to health care provider burnout, patient frustration and can even pose a health risk to patients when it delays their care.

To further explore stakeholder input, ONC is requesting public comment on how the Certification Program can build on existing efforts to reduce the burden of prior authorization tasks. ONC is also seeking stakeholder input on anticipated benefits and burdens of any updates to the Certification Program for providers, health IT developers, and patients.

“Supporting the needs of clinicians and improving patient care are key priorities for ONC,” said Elise Sweeney Anthony, executive director, Office of Policy. “We’re eager to hear from the public about prior authorization and ways to bridge the gap between administrative and clinical data so that clinicians have more time to focus on patient care and patients have a better experience with the healthcare system.”

Dr. Mary Greene, director of the Office of Burden Reduction and Health Informatics in the Center for Medicare and Medicaid Services said, “We support efforts that can serve to advance electronic prior authorization for patients, providers, and payers.  We look forward to reviewing the input received on this RFI and to exploring opportunities for alignment between future ONC policymaking and ongoing CMS initiatives on this critical topic.” 

This RFI also builds on several previous ONC efforts to address this issue. ONC’s February 2020 report, Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs, identified specific challenges associated with the prior authorization process. The report outlined a series of recommendations to improve prior authorization, including leveraging health IT to standardize data and processes around ordering services or equipment; coordinating efforts to advance new standards approaches; and incentivizing adoption and/or use of technology that can generate and exchange standardized data supporting documentation needs.

In November 2020, the Intersection of Clinical and Administrative Data Task Force (ICAD) of the Health Information Technology Advisory Committee (HITAC) provided a report and set of recommendations – PDF to the HITAC on improving data interoperability across the ecosystem through the convergence of clinical and administrative data. Key recommendations focused on establishing standards for prior authorization workflows.

Individuals seeking more information about the RFI or how to provide written or electronic comments to ONC should visit the Federal Register to learn more. Please note that comments must be submitted by March 25, 2022 in order to be considered.

Department of Health and Human Services, Electronic Prior Authorization Standards, HHS, ONC

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