WASHINGTON
A new final rule aims to streamline prescription processes.
Key Takeaways:
- Certified EHRs can now submit prior authorizations.
- Real-time prescription benefit checks will be supported.
- Electronic prior authorization is now a requirement.
- Electronic prescribing standards have been updated.
What’s in the HTI-4 final rule?
A significant final rule, formally titled “Health Data, Technology, and Interoperability: Electronic Prescribing, Real-Time Prescription Benefit and Electronic Prior Authorization,” or HTI-4, has been released. This rule enables certified electronic health record (EHR) systems to handle prior authorizations, select drugs aligned with patient insurance, and exchange electronic prescription information seamlessly with pharmacies and insurance plans.
The HTI-4 rule finalizes proposals from the HTI-2 proposed rule and is part of the Department of Health and Human Services’ fiscal year 2026 Hospital Inpatient Prospective Payment System (IPPS) final rule. It supports the goal of processing prior authorizations in real time during patient encounters.
Real-Time Prescription Benefit Checks Get a Boost
A new certification criterion is in place to support real-time prescription benefit checks. The Consolidated Appropriations Act of 2021 mandated new requirements for both CMS and ASTP/ONC regarding the electronic identification of prescription benefit information. This new criterion allows patients and prescribers to compare drug prices and find more affordable alternatives at the point of care. It aligns with Medicare Part D program requirements and uses standards developed by the National Council for Prescription Drug Programs (NCPDP).
Standardized Electronic Prior Authorization
New HL7 Fast Healthcare Interoperability Resources (FHIR) certification criteria have been adopted to standardize electronic prior authorization. These criteria, which leverage standards from the HL7 Da Vinci Project, aim to improve interoperability between providers and payers. Certified health IT systems will now allow providers to:
- Request coverage requirements from payers.
- Gather necessary information for prior authorization requests.
- Submit requests directly from their EHR.
- Monitor the status of submitted requests.
Health IT modules certified under these criteria will help providers comply with the prior authorization API requirements outlined in the 2024 CMS Interoperability and Prior Authorization Final Rule. Furthermore, these updates will support new Electronic Prior Authorization measures starting in 2027 for Medicare’s Promoting Interoperability program and the MIPS Promoting Interoperability performance category.
Electronic Prescribing Standards Updated
The baseline standard for electronic prescribing has been updated for the first time in five years. The “electronic prescribing” certification criterion now includes an improved version of the NCPDP SCRIPT standard. This update, developed in collaboration with CMS, aims to improve nationwide interoperability between prescriber systems and Part D sponsors. A key change is the requirement for prescriber systems to support electronic prior authorization for prescriptions, a feature that was previously optional.
Through continued collaboration with CMS, these efforts are dedicated to enhancing interoperability for patients, providers, and payers, with the goal of reducing administrative burdens. This final rule represents a significant step forward in those endeavors.
