4 Ways to Capitalize on the Momentum Behind the Proposed CMS Rule

The Centers for Medicare & Medicaid Services (CMS) proposed rule (CMS-0062-P) is poised to transform prescribing and accelerate speed to therapy across the healthcare ecosystem.

Understanding the Proposed CMS Rule 

For EHR vendors and health systems, the proposed rule represents more than a compliance requirement. It represents a strategic opportunity to enhance clinical workflows, inform and accelerate care decisions and improve patient outcomes.

In collaboration with the Office of the National Coordinator for Health Information Technology (ONC), CMS-0062-P extends national interoperability and prior authorization requirements to all drugs across Medicare Advantage, Medicaid fee-for-service and managed care organizations, Children’s Health Insurance Program (CHIP) and qualified health plans (QHPs) on the federally facilitated exchanges.

What makes this rule particularly significant is its comprehensive approach, which represents an expansion of the existing electronic prior authorization (ePA) requirements finalized in 2024 under CMS-0057.

The new rule establishes two sets of ePA standards:

• HL7 FHIR APIs (CRD/DTR/PAS) for medical-benefit drugs administered in clinical settings
• NCPDP SCRIPT, Formulary & Benefit and Real-Time Prescription Benefit (RTPB) standards for pharmacy-benefit drugs

Additionally, it proposes advancing the administrative simplification of the Health Insurance Portability and Accountability Act (HIPAA) by transitioning prior authorization transactions from X12 to FHIR. Separately, the rule proposes that all Medicaid, CHIP and QHP issuers on the federally facilitated exchanges support the NCPDP SCRIPT, Formulary & Benefit and RTPB standards by that same date—putting real-time benefit information within reach across these populations.

While the rule primarily targets payers, EHR vendors and health systems must be prepared to receive and leverage this information through standardized interfaces.

Here are four ways to set your health organization up for success.

1. Integrate Standards-Compliant Tools Now

The proposed rule codifies specific standards that payers will be required to use, and EHR vendors and health systems can begin integrating solutions that already leverage these required standards.

This includes tools built on NCPDP SCRIPT standard for pharmacy-benefit drug prior authorization and HL7 FHIR for medical-benefit drugs. Electronic prior authorization and prior authorization automation platforms that utilize these standards can seamlessly exchange information with payers—accelerating patient access to medications.

By adopting these solutions now, organizations can help speed patient access to therapy and avoid costly retrofits down the road.

2. Invest in Advanced Prior Authorization Solutions

Electronic prior authorization tools replace fax machines and phone calls with digital transactions—an important and meaningful improvement. And prior authorization solutions that automate the process go a step further by directly embedding intelligence into clinical workflows. This means that when a provider prescribes a medication that requires prior authorization, automated systems can check formulary requirements, submit necessary documentation and quickly receive a determination—often in real time rather than over days.

Embedding these checks directly in the prescribing workflow removes the manual touches that slow determinations, so therapy can start sooner.

The proposed CMS rule creates the regulatory foundation for this automation by requiring payers to support the necessary standards. And health systems and EHR vendors that implement truly automated workflows are likely to see the greatest returns in improved medication adherence and patient satisfaction.

3. Leverage Real-Time Benefit Intelligence at the Point of Prescribing

Federal policy is setting a clear expectation: prescription benefit and prior authorization information should be available when prescribing decisions are being made. The CMS rule’s inclusion of Real-Time Prescription Benefit standards for Medicaid, CHIP and QHPs on the Federally Facilitated Exchanges (FFEs) represents a significant expansion of real-time benefit tools across patient populations.

The evidence supporting real-time benefit information is compelling.

• A recent adherence study published in the Journal of Managed Care & Specialty Pharmacy found that real-time benefit information at the point of prescribing improved medication adherence among patients new to diabetes treatment.
• A JAMA Network Open article citing Surescripts data found that real-time benefit information has the greatest impact when it is displayed automatically to prescribers—and it calls for making these tools more user-friendly, patient-specific and clinically relevant.
• A Surescripts impact report further demonstrates how medication intelligence delivered at the right moment can accelerate care decisions and reduce out-of-pocket costs for patients. For example, in 2025, prescribers using Real-Time Prescription Benefit saved patients an estimated $55.1 million dollars combined.

For EHR vendors, this means prioritizing solutions that surface formulary information, coverage details and alternative options directly within prescribing workflows. For health systems, it means selecting and promoting tools that provide this intelligence automatically and within clinician workflows. The more seamlessly information is integrated, the more likely clinicians are to use it—and the greater the benefit to patients.

4. Preparing for the Transition

Meeting the Oct. 1, 2027, compliance date will require careful planning, stakeholder engagement and purposeful workflow changes. Health systems should begin now by assessing current prior authorization volumes, identifying pain points and mapping how automated tools will integrate with existing clinical processes.

It’s also important for clinicians to keep in mind how these changes can benefit patients, including:

• Faster access to medications
• Fewer prior authorization delays and resubmissions
• Improved medication adherence

EHR vendors should work closely with provider organizations to ensure smooth implementation, providing robust training resources, responsive technical support and clear communication about how these capabilities align with the evolving regulatory landscape.

Seizing the Opportunity

The proposed CMS rule represents a significant advancement for prescription drug prior authorization. By establishing clear standards and expanding requirements across major payer segments, CMS is creating unprecedented momentum behind electronic prior authorization and real-time benefit tools.

For EHR vendors and health systems, this is an opportunity to lead. Organizations that take a proactive approach—adopting standards-compliant tools, implementing true automation, leveraging real-time benefit intelligence and preparing workflows—will deliver better experiences for clinicians and patients while positioning themselves for success in an increasingly interoperable healthcare landscape.