ADA urges dental-specific approach in CMS interoperability, prior authorization proposal 

The ADA is urging federal regulators to ensure that dentistry’s unique workflows and health information technology challenges are taken into account as the government advances new interoperability and prior authorization requirements. 

In comments submitted June 11 on a proposed rule from the Centers for Medicare & Medicaid Services, the ADA expressed support for CMS’ broader goal of reducing administrative burden and improving transparency in prior authorization while also cautioning that policies largely designed around medical and pharmacy systems may not translate seamlessly to dental care. 

The proposal would establish new interoperability standards and prior authorization requirements for Medicare Advantage plans, Medicaid managed care plans, Children’s Health Insurance Program entities and issuers of qualified health plans. CMS has said the changes are intended to streamline prior authorization, promote standardized application programming interfaces, or APIs, and improve the secure exchange of information among providers, patients and payers. 

“The ADA commends the Centers for Medicare & Medicaid Services (CMS) for seeking to streamline, clarify and reduce the burdens of the prior authorization process for patients and providers, and for continuing to promote interoperability to facilitate the secure exchange of information between providers, patients and payers,” reads the letter, which was signed by ADA President Richard Rosato, D.M.D., and Executive Director Nader Nadershahi, D.D.S. 

They noted that standardized APIs have the potential to improve efficiency and care coordination, emphasizing that standardized APIs offer more complete information at the point of care, greater efficiency and better coordination of benefits. 

The letter also highlighted that dental practices operate differently from most medical settings. The comments describe dentistry as “predominantly procedure-based, frequently attachment-heavy, and often depends on tooth-specific clinical detail, radiographs, narratives, and multi-visit treatment planning.” 

Those differences, Drs. Rosato and Nadershahi wrote, are especially important when considering prior authorization workflows. Many dental practices also rely on Current Dental Terminology codes and practice management systems that were not designed around the same interoperability capabilities commonly used in medicine. 

They warned that requirements calibrated for large health systems could create unintended burdens for dentists, particularly those practicing in small, specialty or single-site settings. 

“Because many dentists practice in small, specialty, or single-site settings with limited IT and administrative capacity, implementation requirements calibrated to large medical health systems risk shifting administrative burden onto dentists and their teams and, in turn, delaying patient care unless paired with dental-specific testing, phased adoption, and appropriate technical support,” according to the letter.  

Drs. Rosato and Nadershahi commented on the dental software ecosystem, noting that while the proposed rule correctly recognizes that dentists are subject to HIPAA requirements, dental practice management systems have developed in a different regulatory environment from the medical sector. 

“Unlike medical electronic health records, dental practice management systems have largely evolved outside the ONC Health IT Certification Program, without a comparable Promoting Interoperability pathway, Medicaid EHR incentive structure, or other sustained policy mechanism that would require investment in FHIR-enabled functionality,” they wrote.  

A central theme of the ADA’s comments is the need for testing before broad implementation. Drs. Rosato and Nadershahi recommended that CMS conduct pilots across a range of dental practice types, including solo practices, small-group practices, oral surgery practices and dental service organizations. They said such testing should verify that dental-specific data elements and workflows are fully supported before any mandates are finalized or enforced for dental use cases. 

The comments also raise concerns about the readiness of dental software systems. While the proposed requirements would apply primarily to payers, Drs. Rosato and Nadershahi noted that dentists will be directly affected by how well software vendors, clearinghouses and insurers are able to implement the new standards. 

“Many dentists still rely on practice management systems without native Fast Healthcare Interoperability Resources, or  FHIR endpoints and therefore depend on middleware, payer portals, or manual workarounds,” they wrote. “The burden is especially significant for small and solo practices.” 

The letter added that current FHIR profiles do not yet consistently support several data elements commonly used in dental care, including tooth numbering, surface-level restorations, periodontal measurements and odontograms. 

Drs. Rosato and Nadershahi also addressed the proposal’s provisions related to electronic prior authorization for drugs. While electronic prescribing and pharmacy benefit tools are becoming more common throughout health care, the association said dentists often interact with these systems differently than medical providers. 

They said dentists rarely use the National Council for Prescription Drug Programs Formulary and Benefit standard directly in day-to-day workflows, noting that dental providers often access such information indirectly through pharmacy systems or integrated medical e-prescribing platforms. 

The comments highlight potential challenges for dental anesthesiologists and oral and maxillofacial surgeons, particularly when medications do not fit neatly into existing categories of medical or pharmacy benefits. The ADA asked CMS to provide additional guidance on how drugs commonly used in dental settings would be treated under the proposed framework. 

The letter urged CMS to take a measured approach to implementation. It recommended phased adoption timelines, real-world pilot testing, targeted technical assistance and ongoing collaboration with dental stakeholders. It also called on CMS and the Department of Health and Human Services to recognize the ADA’s role in dental coding and standards development and to ensure that dentistry is represented in future interoperability efforts. 

The letter concluded by reiterating the ADA’s support for the goals of the proposal while emphasizing the importance of adapting those goals to the realities of dental practice. 

“The ADA strongly supports CMS’s overall goal of improving prior authorization so that patients and dentists can benefit from a more expeditious, transparent, and reliable process, and we believe that careful attention to the realities of dental practice and patient access will help ensure that these reforms succeed across the full spectrum of health care providers,” Drs. Rosato and Nadershahi wrote.