Interoperability Resources

Federal Interoperability Guidance

Interoperability and Patient Access Final Rule (CMS-9115-F)

The Centers for Medicare & Medicaid Services (CMS) published the 2020 CMS Interoperability and Patient Access Final Rule that requires health plans (like Medicaid) to share health data, provider directory, and formulary (covered) drugs list with members using third-party apps.

Visit CMS.gov to learn more about the Interoperability and Patient Access Final Rule.

Interoperability and Prior Authorization Final Rule (CMS-0057-F)

The Centers for Medicare & Medicaid Services (CMS) published the 2024 CMS Interoperability and Prior Authorization Final Rule that adds rules to getting approvals (called prior authorizations) faster and digital and aims to improve health information exchange to provide appropriate and necessary access to health records for patients, healthcare providers, and payers.

Visit CMS.gov to learn more about the Interoperability and Prior Authorization Final Rule.

Medi-Cal Fee-for-Service Prior Authorization Metrics Reporting

To comply with the CMS Interoperability and Prior Authorization Final Rule, the Department of Health Care Services (DHCS) is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services over the previous calendar year (CY).

Public reporting of prior authorization metrics, which include Prior Authorization Requests (Treatment Authorization Requests (TARs) and Service Authorization Requests (SARs) in the DHCS program, promotes transparency and accountability, helps patients understand prior authorization processes, and enables providers to evaluate payer performance.

Review the prior authorization metrics: Medi-Cal Fee-for-Service Prior Authorization Metrics Reporting.