Comment on CMS-2026-1255-0001

I support CMS’s continued efforts to modernize and standardize prior authorization, particularly the expansion of electronic prior authorization (ePA) to medications. This is a critical step toward reducing administrative burden and improving access to timely care. From a health system and clinical informatics perspective, I would highlight several considerations to ensure the rule achieves its intended impact: 1. Workflow integration must be prioritized over simple digitization. While the proposed APIs enable electronic exchange, requiring true integration of prior authorization into EHR workflows (e.g., FHIR-based, in-context clinical decision support) is essential. Portal-based or fragmented solutions will not meaningfully reduce provider burden. 2. CMS should encourage real-time or near-real-time decisioning. The combination of FHIR APIs and Real-Time Prescription Benefit tools creates an opportunity for point-of-care decisioning. Policies should incentivize immediate approvals where criteria are met, minimizing delays in therapy initiation. 3. Denial transparency should be actionable, not just descriptive. In addition to requiring reason codes, CMS should require that payers provide specific, clinically relevant next steps (e.g., covered alternatives, documentation gaps, or criteria thresholds) in a structured format usable within EHR workflows. 4. Guard against unintended burden shifting to providers. Without usability and integration standards, the operational burden may shift from manual payer workflows to provider teams navigating multiple electronic tools. CMS should consider usability expectations and provider workflow impact as part of compliance and reporting. 5. Support use of AI-enabled documentation and automation. As health systems deploy ambient documentation and AI-assisted clinical tools, CMS should ensure that structured data generated from these tools can be used to populate and submit prior authorization requests without additional manual effort. 6. Strengthen performance measurement. In addition to API usage, CMS should track: Time from order to authorization decision Time to therapy initiation Provider time spent per authorization These measures more directly reflect patient access and clinician burden. Overall, this proposed rule is a strong step forward. With additional emphasis on workflow integration, real-time decisioning, and actionable transparency, CMS can significantly accelerate progress toward a fully modernized prior authorization process.