April 13, 2026
The Centers for Medicare & Medicaid Services (CMS) has released the 2026 CMS Interoperability Standards and Prior Authorization for Drugs proposed rule (CMS 0062 P), advancing its ongoing effort to streamline and modernize electronic prior authorization. The proposal is intended to provide patients and providers with a faster, more transparent, and more reliable prior authorization process. It builds on earlier CMS actions, including the 2020 CMS Interoperability and Patient Access final rule (CMS 9115 F) and the 2024 CMS Interoperability and Prior Authorization final rule (CMS 0057 F), which together established a framework for interoperability APIs across multiple public and private health coverage programs.
While the 2024 final rule focused on non-drug items and services, the new proposal extends many of those requirements to prescription drugs. CMS is proposing that impacted payers, including Medicare Advantage plans, Medicaid, CHIP fee-for-service and managed care plans, and Qualified Health Plans on the federally facilitated exchanges, support electronic prior authorization for drugs, meet shorter and more consistent decision timeframes across CMS programs, and enhance transparency around drug prior authorization decisions. The rule would also require updates to health IT standards and mandate reporting to CMS on interoperability API endpoints and usage metrics.
In addition, under HIPAA’s administrative simplification provisions, the Department of Health and Human Services proposes adopting certain HL7 Fast Healthcare Interoperability Resources (FHIR) standards and implementation specifications for prior authorization transactions. These requirements would apply broadly to HIPAA-covered entities, health-care providers, health plans, and clearinghouses that electronically exchange prior authorization requests and decisions.
The proposed rule is open for public comment through June 15, 2026.