CMS says the 2024 Interoperability and Prior Authorization final rule, CMS-0057-F, was released on January 17, 2024. The Federal Register published it on February 8, 2024, at 89 FR 8758. The Federal Register dates section says the regulations are effective April 8, 2024. Read the CMS overview and the Federal Register document.
The Federal Register summary describes requirements for Medicare Advantage organizations, state Medicaid fee-for-service programs, state CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and issuers of qualified health plans on the federally facilitated exchanges. It also describes new measures for eligible hospitals, critical access hospitals, and MIPS eligible clinicians. The CMS overview says impacted payers implement certain provisions by January 1, 2026, and have until primarily January 1, 2027, to meet the API requirements.
Timeline
January 17, 2024
CMS releases the Interoperability and Prior Authorization final rule (CMS-0057-F)
CMS states that it released the 2024 CMS Interoperability and Prior Authorization final rule (CMS-0057-F) on January 17, 2024.
CMS, CMS-0057-F overviewFebruary 8, 2024
CMS-0057-F is published in the Federal Register
The final rule was published on February 8, 2024, at 89 FR 8758, document number 2024-00895.
Federal Register, 89 FR 8758April 8, 2024
The CMS-0057-F regulations take effect
The Federal Register dates section states that these regulations are effective on April 8, 2024.
Federal Register, DATES sectionJanuary 1, 2026
Certain CMS-0057-F provisions are required
The CMS overview states that impacted payers are required to implement certain provisions by January 1, 2026.
CMS, CMS-0057-F overviewJanuary 1, 2027
API requirements are primarily due
The CMS overview states that impacted payers have until primarily January 1, 2027, to meet the API requirements in the final rule.
CMS, CMS-0057-F overview
State statutes
Only statutes checked against an official legislative page are listed. Absence from this list is not a statement that a state has no law.
California · Chaptered
Senate Bill 1120, Chapter 879, Statutes of 2024
Health care coverage, utilization review
The chaptered bill text says a health care service plan or disability insurer that uses artificial intelligence, an algorithm, or other software for utilization review or utilization management based on medical necessity must meet stated limits. Those limits include not basing a determination solely on a group dataset, keeping the tool open to inspection for audit, and not using the tool to deny, delay, or modify health care services based on medical necessity. The bill text says a medical-necessity determination is made only by a licensed physician or other licensed health care professional competent to evaluate the clinical issues. The chaptered text reviewed for this page does not print a separate operative date. Confirm the operative date on the official bill page. This site does not state one.
Recorded action date: September 28, 2024
California Legislative Information, SB 1120
Illinois · Enacted
Public Act 103-0656
Utilization review and adverse determinations
The act text says that even when a health care plan or utilization review program uses an algorithmic automated process for medical-necessity review, only a clinical peer may make an adverse determination based on medical necessity, and only a clinical peer may review an appeal. Programs that use an algorithmic automated process to decide adverse medical-necessity determinations must use objective, evidence-based criteria that meet the accreditation requirements named in the act. The Illinois General Assembly full-text page lists an effective date of January 1, 2025.
Recorded action date: July 19, 2024
Effective date on the official page: January 1, 2025
Illinois General Assembly, Public Act 103-0656
Federal Register documents tagged prior authorization