What Practices Should Know About the Administrative Simplification Final Rule (CMS‑0053‑F)

The Centers for Medicare & Medicaid Services (CMS) has finalized a major Administrative Simplification rule that will modernize how health care claims attachments are exchanged across the health care system. Known as CMS‑0053‑F, this final rule establishes, for the first time, national HIPAA standards for the electronic submission of health care claims attachments—such as medical records, imaging, clinical notes, and laboratory results—replacing long‑standing manual processes like faxing, mailing, and portal uploads.
CMS fact sheet on the final rule

Why this rule matters

Despite widespread adoption of electronic health records and HIPAA transaction standards, the exchange of claims attachments has remained largely manual for many practices. When payers request additional documentation to adjudicate a claim, practices have often relied on fax machines, scanned PDFs, or mailed records—contributing to delays, administrative burden, and rework.

The CMS‑0053‑F final rule addresses this gap by establishing standardized, interoperable electronic transactions for claims attachments. CMS estimates the rule will save the health care industry approximately $781 million annually, largely by reducing administrative overhead and shortening claims processing timelines.
Overview of expected savings and impact

What the rule does—and does not—cover

This rule is focused specifically on health care claims attachments. It does not apply to prior authorization attachments. CMS intentionally narrowed the scope of the final rule after extensive stakeholder feedback, noting that additional work is needed to align prior authorization standards with existing regulations and workflows.
Details from the Federal Register notice

Key standards adopted

The final rule adopts updated national standards that support secure, structured electronic exchange of both administrative and clinical information tied to claims. These include:

• Updated X12 standards for claims attachment transactions
• HL7 implementation guides to support standardized clinical documentation
• Electronic signature requirements to ensure transactions are authenticated, secure, and compliant with federal regulations

Together, these standards are designed to support faster, more reliable claims adjudication while strengthening data security and interoperability across payers, providers, clearinghouses, and vendors.
CMS summary of adopted standards

Effective date and compliance timeline

The rule is effective May 26, 2026, with a 24‑month compliance period, meaning covered entities must be compliant by May 26, 2028. CMS is encouraging health plans, providers, and technology partners to begin preparing now to ensure a smoother transition and avoid last‑minute implementation challenges.
Effective and compliance dates

What practices should do now

Although compliance is still two years away, early preparation can help practices minimize disruption and take advantage of the efficiencies this rule is intended to deliver. Practices may want to:

• Talk with EHR vendors and clearinghouses about readiness for electronic claims attachments
• Review current workflows for responding to claims documentation requests
• Identify areas where fax‑ or paper‑based processes remain in use
• Plan for future updates to internal policies related to documentation exchange and electronic signatures

Looking ahead

CMS‑0053‑F represents a significant step toward reducing administrative burden and modernizing claims processing nationwide. By replacing fragmented, manual attachment workflows with standardized electronic transactions, the rule aims to help practices spend less time on paperwork and more time focused on patient care—while improving efficiency, security, and consistency across the health care system.

For many practices, the next two years will be an opportunity to streamline workflows, strengthen partnerships with technology vendors, and prepare for a more interoperable future.

Early identification and high‑quality care can make a meaningful difference for autistic children and their families. In partnership with Wellcare, we are inviting North Carolina primary care providers to deepen their expertise in autism screening, evaluation, and ongoing care through a collaborative, case‑based learning experience.

Project ECHO Autism – Medical, led by UNC TEACCH, connects primary care clinicians with an interdisciplinary team of autism specialists through a virtual learning model designed to fit into busy clinical schedules. Participants gain practical, evidence‑based knowledge while learning alongside peers who share similar clinical challenges.

What to expect

The Project ECHO Autism series meets virtually on the 1st and 3rd Mondays of each month from 12:30–2:00 PM, beginning May 4, 2026. Sessions combine short didactic presentations with real‑world case consultation, allowing participants to apply new knowledge directly to patient care. Topics focus on improving screening practices, strengthening diagnostic understanding, and enhancing confidence in caring for autistic children across the continuum.

In addition to clinical learning, participants receive free continuing medical education (CME) credits, contact hours, and continuing education units (CEUs) for attending sessions—removing cost as a barrier to participation.

Who should participate

This series is designed for primary care providers in North Carolina who care for children and want to strengthen their skills in autism‑related screening, evaluation, and management. No prior specialty training in autism is required—just a commitment to learning and improving care for patients and families.

Learn more and register

Full details, including session dates, topics, and registration information, are available on the Project ECHO Autism – Medical website

This post explains how Lantern works, who is eligible, what types of procedures are covered, and what practices should understand when patients ask about surgical options under the State Health Plan.

What Is Lantern?

Lantern is a surgical care program included with the State Health Plan that helps match members with carefully vetted surgeons for planned, non‑emergency procedures. Members enrolled in the Plan are automatically enrolled in Lantern and do not need to take additional steps to sign up. There is no premium for the benefit; the cost is covered by the Plan.

Lantern is not available to members whose primary coverage is Medicare or to certain high‑deductible health plan participants. Members are not required to use a Lantern surgeon, but choosing a surgeon within Lantern’s Network of Excellence allows them to take advantage of the enhanced benefits associated with the program.

The Lantern Difference

A key feature of Lantern is its Network of Excellence™. Surgeons and facilities in this network are individually vetted based on licensure, board certification, fellowship training, malpractice history, reputational review, and outcomes data. Lantern reports complication rates of less than one percent, which is significantly lower than typical industry benchmarks.

Members are also supported by a dedicated Lantern Care Advocate. Care Advocates help explain the benefit, identify appropriate surgeons, coordinate appointments, and support members throughout the entire surgical journey so they can focus on recovery rather than logistics.

Covered Procedures and Costs

Lantern covers more than 1,500 planned, non‑emergency surgical procedures across a wide range of specialties, including orthopedics, spine, cardiac care, bariatric surgery, gynecology, general surgery, gastroenterology, ENT, and interventional pain management. Effective January 1, 2026, bariatric procedures are required to go through Lantern’s Network of Excellence.

When members use a Lantern surgeon, the core components of surgery—including the surgeon, hospital or surgery center, anesthesia, and inpatient stay—are covered at no cost to the member under Lantern, depending on the member’s plan. Some services before and after surgery, such as physical therapy, home health, advanced imaging, and durable medical equipment, are not covered by Lantern and remain subject to standard plan benefits.

Meaningful Savings and Travel Support

Lantern participants may experience meaningful savings. On average, members save between $2,000 and $4,000 per surgery, although actual savings vary based on the procedure and plan design.

If a member needs to travel to receive care, Lantern may cover certain travel‑related expenses, including mileage, lodging for trips over 100 miles, airfare for trips over 200 miles, and a daily per diem for meals and incidentals for the member and one companion. Travel arrangements are coordinated in advance by the Care Advocate.

How Members Use Lantern

For members, accessing Lantern starts with a single phone call. Members are encouraged to contact Lantern if they believe surgery may be necessary, have been advised to have surgery, or already have a procedure planned. A Care Advocate then helps guide them through surgeon selection, scheduling, and next steps.

Additional information for members is available on the State Health Plan website at www.shpnc.gov .

Information for Providers Interested in Becoming a Lantern Surgical Provider

Lantern partners with surgeons, hospitals, and ambulatory surgery centers performance and patient outcomes. Lantern partners with surgeons, hospitals, and ambulatory surgery centers across the country through its Network of Excellence™ .

Surgeons and facilities that participate in Lantern’s Network of Excellence may receive referrals for planned, non‑emergency procedures and work closely with Lantern’s clinical and operational teams. Lantern also notes that it emphasizes clear, transparent reimbursement and aims to reduce administrative burden for participating providers.

Providers in this network are individually vetted based on procedure‑specific experience, credentials, and quality outcomes. Lantern describes its approach as “specialist‑first,” focusing on partnering with providers who consistently demonstrate strong clinical performance, evidence‑based practice, and a commitment to delivering exceptional patient care. 

Providers or facilities interested in learning more about joining Lantern’s Network of Excellence can find additional information and submit an inquiry through Lantern’s specialist page at lanterncare.com/specialists . 

Bottom Line

Lantern is a key part of the State Health Plan’s approach to improving surgical quality while lowering costs for members. By guiding members to highly vetted surgeons and supporting them throughout the surgical process, Lantern helps reduce complications, improve outcomes, and minimize financial burden.

Practices that understand how Lantern works are better positioned to answer patient questions and help members navigate their surgical benefits with confidence.

How Practice Support Can Help

The Practice Support Coaching Team can help practices understand how Lantern fits within the State Health Plan, support staff education, and answer workflow questions when patients raise questions about surgical care.

Recent federal action brings welcome stability to telehealth services for Medicare providers and patients. Congress has formally extended key Medicare telehealth waivers through December 31, 2027, ensuring continuity after a brief lapse earlier this year.

For practices that rely on telehealth—particularly in primary care, behavioral health, rural health, and safety‑net settings—this extension reduces near‑term uncertainty and allows for more confident planning.

Stay Informed on Telehealth Policy

Ongoing telehealth policy changes can be complex and fast‑moving. The Center for Connected Health Policy (CCHP) is a trusted national resource that tracks federal and state telehealth developments. Practices can receive timely updates by signing up for CCHP newsletters at
Center for Connected Health Policy 

Medicare Telehealth Waivers Extended Through 2027

As an update to last week’s developments, the Medicare telehealth waivers that expired on January 30, 2026 have now been formally extended. Congress passed H.R. 7148, the Consolidated Appropriations Act, 2026, and the bill was signed into law last week. Importantly, the legislation retroactively covers the brief lapse period, restoring continuity to Medicare telehealth coverage.

This law extends key Medicare telehealth flexibilities through December 31, 2027, preventing a return to permanent, pre‑pandemic Medicare telehealth policy. These waivers have been in place since 2020, when the COVID‑19 public health emergency began, and have been extended multiple times—often for short periods. This nearly two‑year extension provides greater stability for both providers and patients who rely on telehealth services.

Telehealth Waivers That Are Now Extended

Under the new legislation, the following Medicare telehealth waivers remain in effect through the end of 2027:

• Waiver of location requirements, including both geographic restrictions and originating site rules
• Expanded list of eligible telehealth providers
• Continued eligibility of Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) as Medicare telehealth providers
• Delay of the prior in‑person visit requirement for mental health services when certain permanent telehealth policy requirements are not met
• Delay of the in‑person visit requirement for mental health services delivered via telecommunications technology for FQHCs and RHCs
• Continued allowance of audio‑only telehealth services
• Continued use of telehealth to conduct face‑to‑face encounters for hospice recertification

In addition, the Acute Hospital Care at Home Initiative has been extended through September 30, 2030, allowing participating hospitals to continue providing hospital‑level care in patients’ homes.

Additional Telehealth Provisions in the Law

The legislation also includes several forward‑looking telehealth provisions that practices should be aware of:

• CMS is required to establish billing modifiers by 2027 to identify telehealth services delivered through third‑party virtual platforms and services billed “incident to” another professional service.
• Through calendar year 2027, hospitals may furnish and bill Medicare for cardiopulmonary rehabilitation services delivered to hospital outpatients in their homes via live video.
• The Department of Health and Human Services must issue guidance within one year on best practices for delivering telehealth services to patients with limited English proficiency.
• CMS is required to educate Medicare clinicians by January 1, 2028 on screening for medication‑induced movement disorders in at‑risk patients, including best practices for telehealth screening and how these services should be reflected in billing.

CMS Telehealth Guidance Updates

Following enactment of this legislation, CMS has updated its Telehealth FAQ for Calendar Year 2026 to reflect the restored flexibilities and new expiration dates.

The CMS Telehealth and Remote Patient Monitoring (RPM) Medicare Learning Network (MLN) Guidance, most recently revised in December 2025, remains a primary reference source. However, it has not yet been fully updated to reflect the most recent legislative changes. Some elements—such as references to an in‑person mental health visit within six months—will require revision, as that requirement is now waived through the end of 2027.

At the same time, several telehealth policy changes finalized under the CY 2026 Physician Fee Schedule (PFS) and reflected in the December 2025 MLN guidance remain in effect, as they were not addressed in H.R. 7148.

Telehealth Policies That Continue to Apply

Key provisions from the existing MLN guidance that remain unchanged include:

• Permanent addition of new services to the Medicare Telehealth Services List, eliminating the former “provisional” versus “permanent” distinction
• Removal of frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations
• Allowance for teaching and supervising physicians to meet supervision requirements through virtual presence in appropriate clinical situations
• Clarification of enrollment and billing rules for clinicians furnishing telehealth services from their homes, including options to suppress home address information in PECOS for privacy
• Addition of new CPT and HCPCS codes to the Medicare Telehealth Services List, including codes for multiple‑family group psychotherapy, group behavioral counseling for obesity, certain infectious‑disease add‑on services, and auditory integrated sound processors

The MLN guidance also continues to reflect payment for telehealth services furnished by FQHCs and RHCs through December 31, 2026. Because the broader waivers have now been extended through 2027, FQHCs and RHCs remain eligible under the general waiver authority rather than relying on a more limited carve‑out.

DEA Extends Telehealth Prescribing Waiver Through 2026

Separately, the Drug Enforcement Administration (DEA) has extended the telehealth prescribing waiver for controlled substances through December 31, 2026. This extension allows prescribing without a prior in‑person visit or meeting a statutory exception and represents a clean, one‑year continuation with no new requirements.

This policy continues to suspend the initial in‑person visit requirement under the Ryan Haight Online Pharmacy Consumer Protection Act of 2008. The DEA’s rules apply nationwide and are separate from state requirements and Medicare reimbursement rules. Longer‑term federal prescribing policy remains unresolved, and additional changes may emerge.

How Northwest AHEC Can Help

Your Northwest AHEC Practice Support Team is here to help practices interpret telehealth policy changes and understand how they affect workflows, billing, and patient access. We encourage practices to stay informed through trusted resources like CCHP and to reach out with questions.

Beginning April 1, 2026, several Medicaid managed care plans in North Carolina will change how certain claims are handled. Carolina Complete Health, Trillium Physical Health, and Partners Physical Health will move from post‑payment denials to upfront claim rejections when provider information on a claim is incorrect or incomplete.

This change applies broadly and will impact all provider types that submit claims—not just hospitals.

What’s Changing?

Under this new process, claims with provider data that does not match NCTracks will be rejected immediately, rather than processed and denied later.

Upfront rejections may occur when information such as:

• National Provider Identifier (NPI)
• Taxonomy
• Rendering or billing provider details
• Service location information

is missing, inactive, or does not align with what is on file in NCTracks.

If a claim is rejected upfront, it will not enter adjudication. Providers must correct the information and resubmit the claim.

Who Is Impacted?

These changes apply to ALL enrolled providers who submit claims, including:

• Primary Care Providers (PCPs)
• Medical and surgical specialists (cardiology, orthopedics, neurology, GI, OB/GYN, and others)
• Behavioral health providers
• Group practices
• Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)
• Urgent care centers
• Outpatient clinics
• Ancillary providers (physical therapy, occupational therapy, speech therapy, labs, imaging centers)

If you submit claims, these rules apply to you.

Common Reasons Claims Will Be Rejected

Claims may be rejected upfront if any of the following issues are identified:

NPI Issues

• NPI is not active with Medicaid or Health Choice for the date of service
• NPI is not found on file
• Required billing or rendering NPI is missing

Taxonomy Issues

• Taxonomy does not match NCTracks enrollment
• Taxonomy is not active for the date of service
• Taxonomy is missing or invalid
• Claim is billed under the wrong taxonomy

Service Location Issues

• Service facility NPI is missing or inactive
• Required service location fields are not completed when services are rendered at a location different from the billing address (e.g., CMS‑1500 Box 32/32a/32b)

What Providers Should Do Now

To reduce the risk of upfront rejections starting April 1, practices should take the following steps as soon as possible:

✅ Verify Your NCTracks Enrollment

Confirm that all of the following are current, active, and accurate in NCTracks:

• Billing NPI
• Rendering provider NPIs
• Taxonomy codes
• Service locations

✅ Bill Using the Correct Taxonomy

Ensure the taxonomy on your claim matches your NCTracks enrollment for the services being billed.

✅ Review Claim Form Accuracy

Double‑check that claim fields are completed correctly, including:

• Billing provider information
• Rendering provider information
• Service facility location fields

✅ Use the Provider Billing Manual

Refer to the Carolina Complete Health Provider Billing Manual, particularly sections detailing:

• Where NPIs must be reported
• Where taxonomy codes must be placed
• When service facility location fields are required

If You Receive an Upfront Rejection

If a claim is rejected upfront:

1. Review the rejection code provided.
2. Correct the provider information on the claim.
3. Resubmit the claim.

No appeal is required for upfront rejections.

A Note for Hospital Providers

In addition to upfront rejection changes, beginning April 15, 2026, hospital inpatient claims billed at $250,000 or more will move to pre‑payment review rather than post‑payment review. These reviews will continue to be conducted by 6 Degrees Health and apply to claims processed for Carolina Complete Health, Trillium Health Resources, and Partners Health Management.

Hospitals should be prepared to submit itemized bills proactively for high‑dollar inpatient claims to avoid processing delays.

Bottom Line

Starting April 1, 2026, accurate provider data matters more than ever.

These upfront rejection changes apply to all providers submitting claims. Ensuring that your NPI, taxonomy, rendering provider, and service location information exactly match what is on file in NCTracks is essential to avoid immediate claim rejections and payment delays.

How Practice Support Can Help

Your Northwest AHEC Practice Support Team is available to help practices:

• Review common claim errors
• Understand NCTracks enrollment alignment
• Prepare billing staff for upcoming changes

If you have questions or would like assistance, please reach out to your local practice support coach.