What You Should Know:
– The U.S. Department of Health and Human Services (HHS) has released a new final rule, the Health Data, Technology, and Interoperability: Electronic Prescribing, Real-Time Prescription Benefit and Electronic Prior Authorization (HTI-4).
– The rule implements policies to support the goal of processing prior authorizations in real time during patient care encounters and is a critical step in advancing interoperability for patients, providers, and payers to ease administrative burdens.
3 Key Things to Know About the HTI-4 Final Rule
The HTI-4 finalizes certain proposals from the HTI-2 proposed rule and is included in HHS’s FY26 Hospital Inpatient Prospective Payment System (IPPS) final rule. The rule enables the use of certified Electronic Health Records (EHRs) to submit prior authorizations, select drugs consistent with a patient’s insurance coverage, and exchange electronic prescription information with pharmacies and insurance plans. The HTI-4 final rule introduces several key changes aimed at modernizing healthcare technology and workflows:
- Real-Time Prescription Benefit Checks: A new certification criterion has been adopted to support real-time prescription benefit checks. This implements provisions from the Consolidated Appropriations Act (CAA) of 2021, which enables prescribers to access prescription benefit information at the point of care. This helps patients and prescribers compare drug prices and identify lower-cost alternatives. The policy is based on standards from 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 support standardized, electronic prior authorization. These criteria, which leverage standards from the HL7 Da Vinci Project, will enable providers using certified health IT to request information from payers about coverage requirements, assemble the information needed for a prior authorization request, submit the request directly from their certified system, and monitor its status. This will also support new Electronic Prior Authorization measures in the Medicare Promoting Interoperability program and the MIPS Promoting Interoperability performance category beginning in 2027.
- Updated Electronic Prescribing Standard: The baseline standard for electronic prescribing has been updated for the first time in five years. The “electronic prescribing” certification criterion now incorporates an improved version of the NCPDP SCRIPT standard, which was adopted in collaboration with CMS to support nationwide interoperability between prescriber systems and Part D sponsors. The rule also now requires that prescriber systems support functionality for electronic prior authorization of prescriptions, which was previously optional.
The final rule is effective on October 1, 2025.
