NCQA Comments on CMS’s Advancing Interoperability and Improving Prior Authorization Processes proposed rule

NCQA applauds CMS’s efforts to improve the exchange of health information; supports digitizing prior authorization as an opportunity to improve both patient and provider experience.

March 13, 2023

Chiquita Brooks-LaSure, Administrator
Centers for Medicare & Medicaid Services
Department of Health & Human Services
Hubert H. Humphrey Building
200 Independence Ave. SW
Washington, DC 20201

Attention: CMS-0057-P

Dear Administrator Brooks-LaSure:

The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on the Advancing Interoperability and Improving Prior Authorization Processes proposed rule.

NCQA is a private, 501(c)(3) not-for-profit, independent organization dedicated to improving health care quality through our Accreditation and measurement programs. We are a national leader in quality oversight and a pioneer in quality measurement. Leveraging our strengths as a trusted third party, we are committed to helping organizations navigate the challenges associated with moving toward an equitable health care system. Our mission to improve the quality of health for all Americans, with a focus on health equity and support for meaningful value-based payment models, propels our daily work.

We are pleased to provide comments in the following areas:

  • FHIR® APIs and advancements in prior authorization. We applaud CMS’s efforts to improve the exchange of health information and facilitate appropriate and necessary patient, provider and payer access to health information. We look forward to future proposals from CMS on prior authorization metrics.
  • Accelerating adoption of standards related to social risk data. We appreciate CMS’s interest in accelerating adoption of standards related to social risk data. NCQA has a portfolio of market-leading quality measures and QI standards to advance health equity and combat social risks through reliable data infrastructure.
  • Data standardization and electronic exchange to improve maternal and behavioral health outcomes. We are encouraged that CMS is considering USCDI+ to standardize data elements to help solve our nation’s largest health problems. Our country’s maternal morbidity and mortality crisis requires leveraging digital data to identify needed quality improvement interventions. We are equally encouraged that CMS is exploring electronic exchange of behavioral health information. NCQA is digitizing and stratifying quality measures in both domains to deploy in care settings to advance equitable care.
  • Enabling exchange under TEFCA. We continue to encourage CMS to incentivize standardized data exchange under TEFCA, through CMS programs and value-based payment models. We congratulate HHS on the February launch of the inaugural cohort of Qualified Heath Information Networks.

FHIR APIs and Advancements in Prior Authorization

NCQA supports the timelines outlined in the proposed rule that require all affected payers and providers to adopt the Patient Access API, Provider Access API, Payer-to-Payer Data Exchange API and the Prior Authorization Requirements, Documentation and Decision (PARDD) API by January 1, 2026. This will move the industry toward digital health data that can be used for prior authorization, quality improvement and value-based care.

NCQA recognizes the role of prior authorization in decreasing unnecessary patient procedures and health care expenditures. While there are benefits, prior authorization can be a source of administrative burden on providers, interrupt physician workflows and negatively impact patient experience and access. Current prior authorization policies are based on administrative data and guidelines, and there is broad desire to align them more closely with clinical best practices and treatment guidelines. We believe that digitizing prior authorization—much like the move to digital quality measures—can offer an opportunity to improve both patient and provider experience.

NCQA convened key industry stakeholders to address the burden of prior authorization and utilization management. Stakeholders agreed that standardization and technology solutions will help reduce burden. Establishing common tools, infrastructure, standards and implementation is important for relieving the burden of prior authorization, and allows payer prior authorization decisions to be made more quickly to meet patient needs.

We agree with CMS’s proposal to require affected payers to publicly report certain metrics about their prior authorization processes. NCQA has a long history of developing and implementing national standards for utilization management accountability and oversight. We are the nation’s leader in creating digital (computable and standardized) measures in health care. We welcome the opportunity to collaborate with CMS to develop solutions that tackle this important issue.

Specific data and measures that may be meaningful for patients, clinicians and organizations include:

  • Percentage of services approved, by transaction type.
  • Percentage of denials and appeals.
  • Percentage of overturned denials and appeals.
  • Percentage of reasons for denial and appeal determinations.
  • Percentage of retrospective decisions, and associated outcomes.
  • Decision turnaround time by decision type.
  • Clinician-specific denial and approval rates, by service category.
  • Level of electronic prior authorization automation (and amount of provider burden reduction).
  • Measures stratified by race, ethnicity and other health equity elements.

We also support the concept of “Gold Carding” programs in quality Star Ratings and prior authorization programs. This is a common-sense approach to recognizing and reducing burden on high-performing clinicians who consistently request authorization for appropriate services. We believe Patient-Centered Medical Home (PCMH) and Patient-Centered Specialty Practice Recognition can be an additional factor to complement Gold Card programs. Clinicians in NCQA PCMHs and PCSPs meet rigorous standards for following evidence-based standards of care that align with the goals of prior authorization requirements. Clinicians also meet similar standards for expanded access, population health, quality improvement and are well-documented to improve quality and reduce avoidable utilization.

Accelerating Adoption of Standards Related to Social Risk Data

NCQA was proud to be part of the Biden-Harris administration’s White House Conference on Hunger, Nutrition, and Health, and we remain committed to advancing the adoption of digital data and interoperability standards to address social risk factors. We have a leading role in the Sync for Social Needs coalition—a network of plans, systems, government agencies and EHR vendors—to integrate digital data on social risk factors for standardized exchange across health records using a FHIR-based approach.

Additionally, to create the incentives for health plans and clinicians to address unmet social needs, NCQA introduced a new HEDIS® measure: Social Need Screening and Intervention (SNS-E). This measure helps health plans identify food, housing and transportation gaps among their populations, and connect members with resources necessary to address unmet social needs.

NCQA acknowledges that the SNS-E measure will require advancement of social need data exchange capabilities for providers, plans and community entities. NCQA believes that collecting, documenting and exchanging interoperable social need data is critical to supporting better patient care, reducing duplication of social need screening and achieving more equitable health outcomes.

That is why, in February, the standard-setting bodies of the Sync for Social Needs Coalition (NCQA, The Joint Commission, the National Quality Forum) released a Joint Statement on Digital Health Data Exchange of Social Determinants of Health Assessments. NCQA encourages CMS to use its sub-regulatory authority to align with the recommendation in future rules to accelerate adoption of standards related to social risk:

As leading quality organizations, we believe effective use of person-reported data to meet social needs is a health care quality priority, and FHIR enables interoperable use of this information.

Screening instrument standards are likely to evolve as the practice of assessing and addressing social needs matures. Through discussions with standards developers, patients, clinicians, health care organizations and technology providers, we have concluded that FHIR provides a flexible data model and exchange standard to support the use of social needs data, today and in the future. Specifically, the US Core Observation Screening Assessment Profile, which will be added to US Core 6.0.0 in May, enables exchange of findings on standardized instruments. It also provides guidance on Screening and Assessments, and defines a US Core Simple Observation Profile to communicate clinician-interpreted findings in the absence of patient-reported data.

The balance between flexibility and specificity defined in the US Core Observation Screening Assessment Profile will support multiple methods of data exchange and enable meaningful collaboration among organizations supporting persons with unique social needs. The US Core profile enables data to be shared consistently, efficiently and reliably with clinicians and other entities. We collectively urge the Office of the National Coordinator (ONC) to recommend FHIR US Core 6.0.0, for inclusion in the Standards Version Advancement Process…

We strongly encourage HL7 and ONC to adopt the HL7 FHIR SDOH Clinical Care Implementation Guide, specifically, the Questionnaire and QuestionnaireResponse profiles. Incorporating the profiles in FHIR US Core and supporting their use through sub-regulatory guidance from ONC will support greater adoption of social needs screening and intervention, and other person-reported information valuable for improving quality and equity.

Potential Policy Levers that CMS Could Use to Better Incentivize Use and Interoperability of Social Risk Factor Data

NCQA’s Health Equity Accreditation programs, Health Equity Accreditation and Health Equity Accreditation Plus, focus on the foundation of health equity work, and can help CMS incentivize standardized processes, use and reporting of social risk data. We believe Accreditation can be a primary lever to advance health equity and create the necessary data collection and quality improvement structure to measure, report and improve outcomes for all enrollees.

NCQA’s Health Equity Accreditation Plus is designed to help organizations to address the root causes of inequities by collecting data on social needs and upstream social risks of the communities they serve, and to make data-driven decisions that improve members’ access to and experience with community-based partnerships and resources. The Accreditation aligns with CMS’s efforts to improve health equity and invest in community-based organizations and local support agencies to transform the environments where members live, work and play. It requires organizations to collect social needs information for a core set of domains, in alignment with the Gravity Project.

Nine organizations, including five regional subsidiaries of national health plans (UnitedHealthcare, Elevance, CVS Health, Centene, Molina), two payviders (UPMC, Geisinger) and two health systems (Novant Health, Hennepin Healthcare) participated in the feasibility pilot of both Health Equity Accreditation and Health Equity Accreditation Plus. To date, over 100 organizations have earned Health Equity Accreditation (or its predecessor, Multicultural Healthcare Distinction). Eleven states have already mandated Health Equity Accreditation for one or more product lines or ACOs.

Advancing Interoperability and Improving Prior Authorization Processes for Maternal Health

We appreciate the administration’s commitment to supporting states expanding postpartum Medicaid coverage for up to 12 months. Continuous enrollment supports robust maternal health quality measurement, and quality measures can drive quality improvement efforts to address the maternal health crisis. The interoperable health data elements and standards promulgated through this proposed rule should eliminate the need for a lengthy prior authorization process, which can lead to delayed care and adverse perinatal outcomes.

We are encouraged that CMS has identified maternal health as an important topic for data standardization through USCDI+, and as an “add-on” to the Universal Foundation of measures. NCQA is proud that nearly 70% of the Universal Foundation measures are HEDIS measures, and we urge CMS to identify high-priority, valid and reliable measures for maternal health to add to the Universal Foundation. CMS should “add-on” existing maternal health HEDIS quality measures:

  • Prenatal Immunization Status.
  • Perinatal Depression Screening and Follow-Up.
  • Postpartum Depression Screening and Follow-Up.

All three measures have electronic specifications and support CMS’s move to all digital quality measures in the next decade. NCQA is eager to work with CMS and ONC on the USCDI+ initiative, and we agree that maternal health should be an initial workstream of USCDI+. Data elements defined in USCDI and USCDI+ will support digitization of existing maternal health quality measures, and help CMS and NCQA identify new digital measures to address this issue.

NCQA is currently working with the National Birth Equity Collaborative to understand and improve birth equity through measurement. We look forward to sharing our findings with CMS and the broader public.

Electronic Exchange of Behavioral Health Information

We agree with CMS that limited adoption of EMRs in behavioral health settings presents a challenge for data capture and exchange, and we agree that FHIR APIs are a promising source for incorporating data from non-EMR sources. NCQA has already transitioned many behavioral health HEDIS measures to our Electronic Clinical Data System (ECDS) Reporting method, to allow behavioral health information not captured in claims or EMRs to be identified and used to track, monitor and improve behavioral health outcomes. The following HEDIS behavioral health measures are available and leverage electronic behavioral health information.

  • Depression Screening and Follow-Up for Adolescents and Adults.
  • Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults.
  • Depression Remission or Response for Adolescents and Adults.
  • Unhealthy Alcohol Use Screening and Follow-Up.

We look forward to developing more measures that leverage electronic behavioral health information, and we appreciate CMS’s commitment to integrating behavioral health data across the care continuum.

Advancing the Trusted Exchange Framework and Common Agreement

We congratulate HHS on the major step in advancing interoperable health data through the first round of TEFCA QHINs, and we encourage CMS to continue to incentivize standardized data exchange under TEFCA, through other CMS quality programs and value-based payment models. This will greatly enhance our ability to automatically extract data for quality measurement from both clinical and nonclinical data sources, now and into the future.

We were excited to see that KONZA, an early adopter of NCQA’s Data Aggregator Validation program, is an inaugural QHIN participant. NCQA’s Data Aggregator Validation program allows KONZA to demonstrate data quality to payer partners and reduce physician administrative burden. If CMS chooses to use QHINs and other aggregators for quality measures in its programs, their aggregation methods must validated for reliability and accuracy.

Thank you for the opportunity to comment. We remain committed to working with CMS to build a more equitable, sustainable and responsible American health care system. If you have any questions, please contact Eric Musser, Assistant Vice President of Federal Affairs, at (202) 955-3590 or at


Margaret E. O’Kane

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