By Tom Keane and Steven Posnack, ASTP/ONC
LinkedIn: Steven Posnack
LinkedIn: ASTP/ONC
Rule Creates Prescription Drug Cost Transparency, Eases Administrative Burden, and Speeds Access to Care
ASTP/ONC released a final rule enabling the use of certified EHRs to submit prior authorizations, select drugs consistent with a patient’s insurance coverage, and exchange electronic prescription information with pharmacies and insurance plans.
Formally titled “Health Data, Technology, and Interoperability: Electronic Prescribing, Real-Time Prescription Benefit and Electronic Prior Authorization,” HTI-4 finalizes certain proposals in ASTP/ONC’s HTI-2 proposed rule and is included in HHS’s FY26 Hospital Inpatient Prospective Payment System (IPPS) final rule. In conjunction with the IPPS published by our partners at the Centers for Medicare & Medicaid Services (CMS), the HTI-4 final rule implements policies supporting Secretary Kennedy’s goal of processing prior authorizations in real time during patient care encounters.
What’s in the HTI-4 final rule?
We have adopted a new certification criterion to support real-time prescription benefit checks.
The Consolidated Appropriations Act (CAA) of 2021 added new requirements for both CMS and ASTP/ONC related to real time electronic identification of prescription benefit information. Patients and prescribers can use the tools we are adding to certification to compare drug prices and identify lower cost alternatives. In HTI-4, ASTP/ONC is implementing the provisions of the CAA by adding a new certification criterion enabling prescriber access to prescription benefit information at the point of care. This policy complements requirements in the Medicare Part D program and is based on common standards for real-time prescription benefit exchange developed by the National Council for Prescription Drug Programs (NCPDP).
We have adopted new HL7® Fast Healthcare Interoperability Resources® (FHIR®) certification criteria to support standardized, electronic prior authorization.
These criteria leverage standards from the HL7 Da Vinci Project to support prior authorization interoperability between providers and payers. The criteria enable providers using certified health IT to: request information from payers about coverage requirements; navigate and assemble the information needed to support a prior authorization request; submit that request directly from their certified health IT system; and, monitor the status of a request.
Health IT Modules certified to these criteria will enable health care providers to interact with the prior authorization API requirements established in the 2024 CMS Interoperability and Prior Authorization Final Rule. These criteria will also support reporting on new Electronic Prior Authorization measures in the Medicare Promoting Interoperability program and the MIPS Promoting Interoperability performance category beginning in 2027.
We have also updated the baseline standard for electronic prescribing for the first time in half a decade.
The “electronic prescribing” certification criterion now incorporates an improved version of the NCPDP SCRIPT standard. ASTP/ONC adopted the standard last year in collaboration with CMS to support nationwide interoperability between prescriber systems and Part D sponsors. We also now require that prescriber systems support functionality for electronic prior authorization of prescriptions, which until now was optional in the program.
Through ongoing collaboration and coordination with CMS, we are committed to advancing interoperability for patients, health care providers, and payers to ease administrative burdens. This final rule is a critical step in these efforts.
This article was originally published on the Health IT Buzz and is syndicated here with permission.