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The Centers for Medicare and Medicaid Services issued the CMS Interoperability and Prior Authorization Final Rule, which established new requirements for certain impacted payers. Several provisions take effect during 2026, including requirements related to prior authorization metrics and operational improvements. The rule also sets expectations around faster decisions and electronic prior authorization processes, with some API requirements taking effect in 2027.

A useful workflow begins when the clinic receives an authorization-related fax or email and ends when the case is approved, denied, withdrawn, completed, or escalated for human intervention.

Automation should reduce manual work without expanding unnecessary access to protected health information. The U.S. Department of Health and Human Services HIPAA Security Rule requires covered entities and business associates to implement administrative, physical, and technical safeguards for electronic protected health information.