How a CMS Proposed Rule Would Bridge the Divide Between EHRs and Payers on Electronic Prior Authorization

The following is a guest article by Tyler Wince, VP of Product & Technology for Specialty Solutions at DrFirst. This article is the next in the Healthcare Regulatory Talk series.

Prior authorization is a workflow with the ability to frustrate providers, payers, and patients in equal measure.

Sending and receiving electronic prior authorizations (ePAs) are two halves of the same workflow, but until now, only one half was on a path to a modern standard. That may be about to change with a new proposed rule to fix the broken half of it—bringing potential workflow improvements as well as technological challenges.

A year ago, the Office of the National Coordinator for Health IT (ONC) finalized a rule requiring electronic health record (EHR) vendors to send PA data using HL7 Da Vinci standards. Now, the Centers for Medicare & Medicaid Services (CMS) has proposed a rule requiring that payers use that same standard.

CMS-0062-P would align mandates for both parties, replacing a partially manual workflow with an end-to-end electronic one. It finishes the work started by the Health Data, Technology, and Interoperability (HTI-4) final rule.

Replacing a 30-Year-Old Standard

For the first time since 1996, the industry is moving away from the rigid X12 278 standard for medical ePA, replacing it with a modern, FHIR-first stack built on Da Vinci. CMS describes this transition as a sea change in HIPAA Administrative Simplification.

Here’s the bottom line: Aligning these mandates ensures that when an EHR sends a Da Vinci-based request, a payer on the other end is required to process it using the same standard.

HTI-4 requires EHRs to support the Da Vinci CRD, DTR, and PAS implementation guides for ePA.
CMS-0062-P would require impacted payers, including Medicare Advantage, Medicaid/CHIP, and Qualified Health Plan (QHP) issuers, to support the same Da Vinci implementation guides (IGs) for medically billed PAs by October 1, 2027.

What Is Da Vinci?

The HL7 Da Vinci Project is a multi-stakeholder accelerator developing FHIR-based IGs that standardize how providers and payers exchange data. For readers who want the technical details, the three IGs doing the heavy lifting are:

Coverage Requirements Discovery (CRD): Surfaces payer rules in the provider’s workflow in real time.
Documentation Templates and Rules (DTR): Gathers the clinical documentation a payer requires to make a decision.
Prior Authorization Support (PAS): Submits the request and returns the determination.

Together, they form the end-to-end electronic loop for ePA.

Everything Else CMS-0062-P Proposes

If finalized as written, the rule would require:

Expedited timelines: Decisions for standard PA would have to be made within 72 hours, down from the current 15-day window, and expedited PA decisions must be made within 24 hours.

PA transparency: Payers would have to provide specific denial reasons and publicly report PA metrics starting in 2028.

API transparency: All API endpoints would have to be listed in a centralized CMS directory. For vendors, this directory reduces the cost and complexity of discovering and maintaining payer connections.

Medical benefits: The 2024 rule, CMS-0057-F, focused on improving information exchange for medical benefits and notably excluded medications administered under the medical benefit. CMS-0062-P applies to all medically billed PAs, including services and medical-benefit drugs—but not pharmacy benefit drugs, which are governed by separate National Council for Prescription Drug Programs (NCPDP) standards.

Key takeaway: With HTI-4 compliance deadlines locked in and decision windows shrinking, EHR vendors cannot afford to treat PA as a back-office afterthought. The infrastructure must be ready before the regulation takes effect.

How DrFirst Supports Pharmacy and Medical PAs

CMS-0062-P addresses one slice of the PA landscape, but providers don’t experience PA one slice at a time. A single patient visit can result in PA needs across medical-benefit services, medical-benefit drugs, and pharmacy-benefit drugs—and right now each is governed by different rules, standards, and payer workflows.

This leaves system vendors with two choices. Either spend the internal time, focus, and capital on building solutions to meet multiple, continually changing standards, or find a trusted partner to manage the complexity for you and ensure that your EHR is always up to date and compliant.

For ambulatory and acute care EHRs, the DrFirst Total Benefits tool handles medical and pharmacy benefits in a single interface, routing requests through Da Vinci IGs for medically billed PAs and NCPDP standards for pharmacy drug PAs.

The HTI-4 final rule provided a catalyst for more refined ePA, and the CMS-0062-P proposed rule would standardize data for even more streamlining. This regulatory tailwind is a call to action, and we are helping vendors move beyond mere compliance to lead the next era of healthcare interoperability.

The comment period for CMS-0062-P ends June 15, 2026.

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Don’t wait to start planning. As a leader in e-prescribing, medication management, and compliance, DrFirst offers turnkey solutions that take the friction off your plate and keep you ahead of shifting regulations. To map your path to compliance with one of our experts, click here.

About Tyler Wince

Tyler Wince, VP of Product & Technology for Specialty Solutions, is a co-founder of Myndshft, which was acquired by DrFirst in 2024, where he led development of the company’s automated prior authorization solution. He’s a software engineer and data scientist who understands the complexities of specialty pharmacy workflows. Check out all the articles in the Healthcare Regulatory Talk series.

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