The demand for administrative simplification, particularly related to prior authorization, continues to increase

On December 15, 2022, the Department of Health and Human Services (HHS) issued a proposed rule for the Adoption of Standards for Health Care Attachments Transactions and Electronic Signatures, and Modification to Referral Certification and Authorization Transaction Standards. HHS states “this rule would adopt a set of standards for the electronic exchange of clinical and administrative data to support prior authorizations and claims adjudications” that will “reduce burden on providers and plans, and result in more timely delivery of patient healthcare services.” HHS cites research performed by the Council for Affordable Quality Healthcare (CAQH), which determined the industry could save as much as $828 million per year in costs associated with prior authorization and claims activities.

The demand for administrative simplification, particularly related to prior authorization, continues to increase. The rules proposed, in addition to separate recently-proposed rules related to prior authorization simplification, continue to acknowledge and support the demand for more timely, efficient, cost-effective processes that facilitate access to care and reduce administrative burden. There are currently no standards, implementation guides, or operating rules for healthcare attachments or electronic signatures, which the proposed rule intends to address as one necessary step on the administrative simplification journey.

HHS is proposing:

  • Definition of “Attachment Information”
  • A code set for healthcare attachments transactions
  • X12 standards for requesting and transmitting information
  • HL7 standards for clinical information content
  • Electronic signature standards
  • Modifying existing standards for referral certification and authorization (X12 278) by updating from Version 5010 to Version 6020

Covered entities will have 24 months after the effective date of the final rule to comply with new requirements. CMS is currently accepting comments on the proposed rule through March 21, 2023.

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