Legislation Detail

Requires federally funded health plans to implement FHIR-based APIs for electronic prior authorization. Sets decision turnaround deadlines, requires justification for denied requests, mandates public reporting of PA metrics, and requires payer-to-payer data exchange. Creates the digital infrastructure enabling AI-driven automation of prior authorization.

Medicare Advantage plans, Medicaid Managed Care organizations, CHIP plans, certain Qualified Health Plans on ACA exchanges

CMS

While not explicitly mandating AI, this rule creates the standardized electronic data exchange infrastructure that makes AI-driven PA automation feasible.