Make compliance useful in practice.

CMS’s interoperability requirements are creating new and expanded ways to handle prior authorization and exchange information. Publishing the API is not the end of the job. The organizations and people entitled to use it still need a working connection.

The rule in four parts

Prior authorization: support electronic requests and responses for the covered scope.

Provider access: make permitted payer-held information available to eligible treating providers under the applicable rules.

Patient access: expand the information members can access through authorized applications they choose.

Payer-to-payer exchange: exchange relevant history between payers under the required member permissions and other conditions.

Covered payer categories, effective dates and any extensions or exemptions are defined by the rule itself; consult the official CMS materials for exact scope and dates. Not every commercial plan is covered, and operational and API requirements can carry different dates. Proposed expansions are not final obligations.

The deadline is not a business model.

Plans remain responsible for the requirements applying to their products. SHN participation and testing are not CMS certification or a substitute for that responsibility.

Supported prior-authorization exchange has no SHN network or transaction fee. Required connection software and status are part of the included service. Optional operating and software services have separate terms; details are on the Open Access page.

Prepare together

The monthly Cut Paperwork, Not Care | Action Forum and hands-on testing events are opportunities to compare progress, resolve obstacles and reuse working approaches. The Delaware implementation page carries the planned schedule.

Synthetic testing is open now. Limited production for ready medical prior-authorization workflows begins December 1. January 1 remains the medical-PA production focus.