What Is CMS-0062? DrFirst Advocates for Electronic Prior Authorization Reform

Every fax, phone call, and portal entry in the prior authorization process adds hours, and sometimes days, to a patient’s time-to-therapy. The Centers for Medicare & Medicaid Services (CMS) is moving to close that gap with a new proposed rule. CMS-0062 would standardize electronic prior authorization (ePA) across the industry, replacing today’s mishmash of manual, portal-based workflows.

At DrFirst, we believe these proposed changes are a meaningful step toward a fully electronic, transparent prior authorization process. We recently submitted formal comments to CMS to share our perspective on how these rules can finally bridge the administrative divide between medical and pharmacy benefits.

How will CMS-0062 help eliminate reliance on payer portals?

For too long, electronic prior authorization has been a manual, click-intensive process requiring providers to log into separate payer portals.

In our comments to CMS, we emphasized that the Direct Data Entry (DDE) portal exception must be curtailed. A firm sunset date for this exception will help ensure that payers are not merely checking a box for digital compliance while keeping providers stuck in legacy workflows. Moving away from portals is essential to reducing clinician burnout and improving patient access to therapy.

How can benefit determination workflows be improved?

A significant operational bottleneck is the “same drug, different benefit” issue, where providers cannot easily distinguish whether a specialty drug falls under a medical or pharmacy benefit.

To solve this, DrFirst advocates a computable, real-time solution to streamline benefit determination:

• Mandate the CRD Information Extension: We recommend CMS require payers to populate a type of benefit field within the Coverage Requirements Discovery (CRD) response. This acts as a definitive traffic signal, routing the transaction to the correct workflow automatically.
• Use NCPDP Coverage Restriction Codes (CRCs): By leveraging existing Codes 816 and 817 in real-time prescription benefit (RTPB) exchanges, PBMs can signal when a drug is ineligible for pharmacy benefits but may be covered under the medical benefit, eliminating the ping-pong effect of misrouted requests.

In some cases, the payoff is often avoidance, not just faster routing. As DrFirst Chief Medical Officer Colin Banas, M.D., M.H.A., points out, “You can actually avoid prior authorization simply by attaching the appropriate ICD-10 code.” So surfacing that requirement at the point of prescribing can keep the transaction out of the PA queue entirely, he adds.

Why is broad adoption of interoperability standards critical?

The success of CMS-0062 depends on a unified approach to technical standards. We strongly support the rule’s dual-track architecture:

• Medical benefit track: Using HL7 Da Vinci FHIR standards (CRD, DTR, and PAS) for physician-administered drugs and medical services.
• Pharmacy benefit track: Using NCPDP SCRIPT 2023011 for self-administered medications.
• Centralized API directory: CMS must maintain a mandatory, public directory of all payer API endpoints to simplify discovery and reduce the integration burden for EHR vendors.
• Transparency and metrics: Starting in 2028, payers should be required to publicly report PA metrics and provide specific, actionable reasons for every denial.
• Firm compliance deadlines: We urge CMS to maintain the October 1, 2027, deadline for payer compliance to ensure the industry moves in lockstep.

Tyler Wince, DrFirst VP of Product & Technology, writes in Healthcare IT Today that these standards are the essential common language enabling EHRs and payers to stop talking past one another.

“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,” Wince said.

What is needed to ensure payer API accountability?

Technical standards won’t work if they are not implemented consistently. DrFirst recommends creating a high-accountability environment for payers:

Dr. Banas sees the move from voluntary payer pledges to enforceable standards as overdue, noting that “CMS is finally putting their foot down.” That regulatory pressure is exactly what makes public reporting and a firm compliance deadline meaningful rather than aspirational.

Preparing for the future of electronic prior authorization.

The transition from legacy standards to a modern, interoperable stack is a significant lift, but the operational benefits—less administrative burden and faster time-to-therapy—are clear.

Standardized and enforceable timelines turn that vision into an expectation. Under the proposed rule, Dr. Banas notes, “You are required to provide an answer within 24 hours, not a week.”

Through our Total Benefits solution, which unifies medical and pharmacy PA workflows, and our ongoing regulatory advocacy, DrFirst is committed to moving the industry toward a frictionless future.

Ready to streamline your prior authorization workflow?

Visit the DrFirst website to learn how our electronic prior authorization solutions for specialty medications help patients get on therapy faster without adding administrative burden.

Read our comments to CMS.