Beginning January 1, 2027, impacted payers must meet the application programming interface (API) provisions in the Centers for Medicare & Medicaid Services (CMS) Advancing Interoperability and Improving Prior Authorization Processes final rule. We sat down with Chief Transformation & Innovation Officer Maraya Thorland to talk about what the rule means and how EviCore by Evernorth has prepared to help health plans with compliance.
Would you start by telling us what this rule is meant to do?
At its core, this rule is about making it easier for computer systems to exchange and use data—what’s known as interoperability. APIs play a key role in interoperability by providing protocols that help software programs communicate. In health care, using APIs as part of electronic medical record (EMR) systems makes it easier for members, providers and payers to receive and share health information.
That’s important because when stakeholders use different languages and terminology in their systems, it makes it more difficult and burdensome to get things done and ensure members get high-quality care in the right place at the right time. With this rule, CMS set out to address that problem by streamlining prior authorization processes through better interoperability, which is consistent with our long track record of advancing innovation.
How well is EviCore prepared to help payers comply with the rule?
Because we’ve been focused on transforming prior authorization processes for many years, we’re strongly positioned to help health plans meet these new requirements. Our investments in technology, interoperability and clinical workflows are already designed to enable many provisions of the rule.
Some provisions in the rule are already in place:
- Turnaround times: The rule requires most impacted payers to make prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests. EviCore’s average turnaround times were already shorter than the requirements specified by the rule. The requirements themselves strike the right balance of ensuring there’s time to collect missing clinical information or have a peer-to-peer discussion with a provider if needed while also ensuring patient care can continue to move forward in a timely manner.
- Provider notice: The rule requires impacted payers to provide a specific reason for denied prior authorization decisions. At EviCore, if we find a prior authorization request doesn’t meet evidence-based standards, we already provide details about why, citing specific clinical guidelines (and have for years). Our guidelines are freely accessible to anyone; we’ve long been committed to this level of transparency, which is aligned with the goals of the rule.
The provisions related to interoperability take effect on January 1, 2027:
- In terms of prior authorization APIs, EviCore is already using Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) X12 278 prior authorization transaction standard. That means health plans that delegate services to EviCore will have access to compliant APIs, helping meet a critical part of the CMS requirements. Health plans and covered entities can use FHIR or a combination of FHIR and X12 278 during the early years of the rule’s implementation.
Can you talk a little bit more about how EviCore got to this point, particularly around innovation?
EviCore has a long history of working to create more effective, collaborative and transparent prior authorization processes through data, technology and innovative approaches. For example, EviCore intelliPath® plays a central role in how we’re meeting the API requirements of the mandate.
EviCore intelliPath® seamlessly connects to EMRs to automate case creation and submission, enabling EviCore and its health plan partners to meet the AHIP prior authorization commitments. When additional information is needed, the APIs can automatically request and ingest clinical data directly from the connected EMR, reducing administrative burden and cutting overall turnaround times in half.
EviCore intelliPath® is already live with more than 260 provider systems, and providers of over 60 health plans take advantage of this technological innovation. The program also has relationships with 13 channel partners, with six more in process for 2026.
As an added benefit, these capabilities are also helping our health plan partners meet AHIP’s prior authorization commitments, which include the adoption of FHIR-based APIs, reaching near–real-time authorizations for up to 80% of approvable requests with clinical documentation and improved transparency around determinations.
How can health plans get more information?
As the January 2027 deadline approaches, EviCore will continue building on these capabilities to support our health plan partners. Contact us for more information about how we are working to enable compliance with CMS requirements.
EviCore intelliPath® is deployed by provider organizations to automate and simplify submitting and tracking requests for prior authorization. intelliPath streamlines operations within a single easy-to-use application that integrates with major electronic health record (EHR) vendors. Costs are reduced and decisions are communicated in real time, reducing delays.
