June 15, 2026
Re: Interoperability Standards and Prior Authorization for Drugs Proposed Rule (CMS-0062-P; RIN: 0938-AV44)
Dear Administrator Oz and Dr. Keane:
Thank you for the opportunity to provide comments in response to the Request for Information (RFI) on Electronic Event Notifications for Value-Based Care and Care Coordination included in the Interoperability Standards and Prior Authorization for Drugs
Proposed Rule.
Accountable for Health is a non-partisan, national advocacy and policy organization accelerating the adoption of effective accountable care. We aim to support policymakers to advance the movement in the health care system toward accountable care that achieves better outcomes, improved care experiences, increased access, and lower costs.
Data is foundational to success in accountable care arrangements, and few data sources are more important than timely access to admission, discharge, and transfer (ADT) notifications. Accountable care providers cannot effectively manage quality and total cost of care if they do not know when an aligned beneficiary has been hospitalized, discharged, or treated in the emergency department. Real-time ADT notifications allow providers to serve as the “quarterback” of a patient’s care by initiating timely follow-up, reconciling medications, coordinating with specialists and post-acute providers, and addressing issues before they result in another emergency department visit or
readmission.
Since May 2021, CMS has required hospitals to electronically notify a patient’s established providers of admission, discharge, and transfer events (42 CFR 482.24(d)). In practice, however, accountable care organizations (ACOs) bearing financial accountability for total cost of care often struggle to receive these notifications reliably, completely, or in time to intervene. Our members face a range of barriers that can be grouped into the following three categories:
- Do Not Receive ADT Feeds for Entire Patient Population: Our members report that their ACOs do not receive ADT feeds for their entire aligned populations but instead have 60-70% coverage with a 30-40% gap. Several factors contribute to these coverage challenges:
- No explicit mandate to notify ACOs. The May 2021 CoP requirement (42 CFR 482.24(d)) requires hospitals to send ADT notifications to a patient’s established providers, but it does not explicitly require notifications to ACOs. Many hospitals interpret this narrowly, sending notifications only to the PCP on file, which may not be current, rather than to the ACO responsible for managing total cost of care.
- No standardized roster ingestion. The absence of a standard format or process for ACOs to submit patient rosters to hospitals means every
connection is a custom build. This is unsustainable at scale and creates significant barriers to achieving comprehensive beneficiary coverage. - State-level consent barriers. States with opt-in HIE consent models, including California, New York, and Massachusetts, create significant coverage gaps. Our HIE authorization rate among Medicare patients is currently around 55%, meaning nearly half of our patients are invisible to us through HIE channels in those states.
- Technical fragmentation and cost. The ADT ecosystem is fragmented across dozens of HIEs, aggregators, and direct connections, each with
different standards, contracts, and pricing. Smaller and newer ACOs face disproportionate barriers to establishing comprehensive coverage across their aligned populations.
- Do Not Receive Timely ADT Feeds: Even when ADT notifications are received, delays can significantly diminish their value. When notifications arrive 48-72 hours after discharge, the window for effective transitional care has often closed. Postdischarge follow-up within seven days is a quality measure, but achieving it requires notification within hours, not days.
- ADT Feed Utility Is Limited by Incomplete Information: Receiving an ADT notification does not necessarily mean the information is actionable, as alerts may contain incomplete diagnosis information, limited clinical context, or duplicate records that require significant cleaning, matching, and de-duplication before they can be incorporated into care management workflows. There is also no enforcement mechanism for data completeness.
Taken together, these barriers mean that the CoP requirement, while meaningful in intent, has not delivered consistent and reliable ADT notification flows to the accountable care entities that need them most. Our responses to specific questions of the RFI are below.
What additional information should be included in patient event notifications, beyond the minimum set of information that hospitals are currently required to send (patient name, treating practitioner name, and sending institution name), for more effective and useful patient event notifications to better support transitions of care?
The current minimum data set, limited to patient name, treating practitioner name, and sending institution name, is insufficient to support the care coordination activities for which ACOs rely on ADT information. Based on the operational experience of our members, the
following fields should be required in all ACO-directed ADT notifications: patient demographics, admission/discharge/transfer type, admitting diagnosis, attending physician, discharge disposition, and payer information. Approximately 60% of ADT messages received by our members are missing one or more of these critical fields, and there is currently no enforcement mechanism for data completeness. CMS should define and enforce this minimum data set for all ACO-directed ADT notifications.
What are the challenges with standardizing patient event notifications?
Standardization of ADT notifications has proven difficult for several interconnected reasons. There is no industry-standard data file specification, resulting in significant inconsistencies in what hospitals send, how they encode it, and what fields they include. Every interface requires customization. Even hospitals using the same underlying EHR platform configure their instances differently, meaning that a connection built for one hospital does not transfer cleanly to another. The operational cost of managing this fragmentation falls disproportionately on ACOs. Currently, the ACO bears the cost of aggregating, cleaning, deduplicating, and finding the signal within the data that is being sent. For organizations operating across dozens of states and managing connections with numerous vendors and HIEs simultaneously, this represents a significant share of total organizational resources, including both engineering staff and non-clinical care coordinators dedicated to reconciling conflicting information. For a family or independent practice, the operational and financial burden makes this effectively out of reach entirely.
A related standardization challenge is the role of EHRs in the notification ecosystem. While some EHR platforms may surface ADT data through their closed systems, this data is accessible only as a point-of-care, transactional view. It cannot be extracted to a data warehouse, queried systematically, or used in population-level workflows. It stays within an isolated area of the EHR and is not available for the downstream analytics and care management functions that ACOs depend on, including monitoring admission trends in near real time, running leading KPI dashboards, and supporting central care management teams that scan across the full attributed population for patients requiring follow-up.
Policies that push standardization through EHR certification without explicitly requiring data extractability risk moving ADT data from accessible aggregated feeds into EHR silos where it is technically present but operationally inaccessible.
On roster-based matching, CMS should define a standard roster file format, building on existing BAR file structures, and require Medicare-participating hospitals to accept and process ACO patient rosters for ADT alerting. The ability to submit an attributed patient list and receive notifications for all patients on that list is, in our members’ experience, virtually nonexistent at scale. A national standard eliminates the current patchwork of custom builds and is the single most important structural change needed to make the CoP work as intended for accountable care entities.
How are ACOs or payers that are currently receiving patient event notifications receiving them? What innovative strategies have ACOs or payers employed to receive patient event notifications? Do ACOs or payers that receive patient event notifications use the information in a meaningful way?
A4H members use ADT event notifications extensively and derive meaningful clinical and operational value from them. Timely ADT data enables proactive discharge planning and care coordination, including scheduling PCP follow-up within three days of discharge; real-time performance tracking, including monitoring admission and readmission trends before claims data is available; population-level surveillance, such as detecting spikes in condition-specific admissions during high-acuity periods; and support for central care management teams who scan for high-risk patients requiring follow-up across a full attributed population. Quality measures tied to post-discharge follow-up are directly and measurably affected when notifications are absent or delayed. Where members do not receive timely notifications, timely follow-up is not possible, and this creates a ripple effect across outcomes and quality scores.
To receive ADT notifications today, our members have built layered infrastructure drawing on multiple source types simultaneously. Health Information Exchanges (HIEs), both national and regional, accessed via Carequality and regional exchange networks, provide broad coverage but with significant variation in timeliness and data completeness depending on how individual hospitals are configured. Third-party vendors consolidate feeds from multiple hospital systems and can approach 80% national coverage but introduce latency typically up to 72 hours and have gaps where hospitals or post-acute facilities do not publish to these networks. For high-volume health system partners, some members maintain direct point-to-point HL7v2 ADT integrations, which are the most reliable and real-time but require significant technical investment and ongoing relationship management with each individual facility. The scale of this infrastructure investment means that for an independent or solo practice, in our members’ experience, it is effectively out of reach.
Across these sources, our members receive ADT notifications for approximately 60–80% of their attributed patient populations, with wide variance by market. Some markets particularly where a mature state HIE or dominant aggregator has achieved broad participation that approaches 90% coverage. Others fall as low as 30–40%, typically where a large health system has not connected or state HIE infrastructure is underfunded or technically dated. We recommend that CMS prioritize policies that strengthen HIE infrastructure by making HIEs more open, stable, and capable, alongside requirements for hospital participation in HIEs and national aggregator networks.
What actions should CMS consider, such as updating the hospital CoP, that would encourage or require hospitals to exchange alerts with any ACO and other PAC provider and supplier types or payers to which a patient is attributed or assigned?
CMS should maintain and strengthen current requirements related to event notifications and move from a flexible, guidance-based approach toward enforceable standards with clear compliance expectations. Several specific, near-term actions could include:
- Establish a standardized roster submission format and standard exchange protocols. CMS should define a standard roster file format (building on existing BAR file structures) and require Medicare-participating hospitals to accept and process ACO patient rosters for ADT alerting. A national standard eliminates the current patchwork. Require minimum data elements in ACO-directed ADT notifications.
- Require minimum data elements in ACO-directed ADT notifications. Define and enforce a minimum data set: patient demographics, admission/discharge/transfer type, admitting diagnosis, attending physician, discharge disposition, and payer information.
What processes are in place for attribution and patient matching between hospitals and ACOs or other value-based care arrangements, payers, PAC facilities, longterm care facilities, social service providers, EMS providers, behavioral health providers, etc.? Are these adequate? What is missing from these processes?
Attribution and patient matching between hospitals and ACOs is one of the most significant operational gaps in the current ADT ecosystem, and existing processes are inadequate.
The most functional approach our members have implemented is a roster-based model, in which lists of attributed beneficiaries are transmitted to hospitals and aggregators so they can alert the ACO when those patients present in the emergency department (ED), are admitted, or are discharged. However, only approximately 40% of hospitals accommodate this approach. Larger health systems with mature IT infrastructure are more likely to support it; smaller community hospitals and critical access hospitals frequently lack the technical capability or operational bandwidth to ingest and match against external rosters.
Where roster-based matching does exist, there is no standard format or submission process. Every hospital requires something different, including different file formats, different transmission methods ranging from SFTP to portal upload to fax, and different refresh cadences. For an organization operating nationally across multiple markets, this creates an enormous administrative burden, and the absence of a national standard means every new hospital relationship requires a custom build from scratch.
For hospitals that do not accommodate rosters, matching depends entirely on the hospital independently identifying a patient’s established provider at the point of care, a process that is inconsistent and frequently fails when attribution data is not current. This is compounded by the fact that notifications typically originate from EHR scheduling systems, but large health systems heavily host and configure their EHR instances, meaning ACOs cannot go directly to the EHR vendor and must instead work through each hospital’s individual technical staff.
The consequences of these attribution and matching inconsistencies compound the existing timeliness and completeness gaps. Timeliness suffers because notifications that depend on manual or inconsistent matching frequently arrive hours or even days after the triggering event, well past the window for meaningful intervention. For ED treat-andrelease events, notifications often arrive after the patient has already left the facility. There is also a signal-to-noise problem: alerts fire for every patient movement within the hospital, and care coordinators must track patients moving from the ED to imaging to the surgical suite and back, making it difficult to identify the events that actually require action.
The gap extends beyond hospitals entirely. Post-acute facilities, including skilled nursing facilities and home health agencies, are not currently required to send ADT notifications, leaving ACOs without visibility during a critical phase of care transition. The requirement should be extended to these settings.
We recommend that CMS should define a standard roster file format (building on existing BAR file structures) and require Medicare-participating hospitals to accept and process ACO patient rosters for ADT alerting. A national standard eliminates the current patchwork.
What technical approach(es) would provide additional functionality/ value to the patient event notification process?
Accountable care entities benefit from data sources – including clinical data, charge data, claims data and HIE/ADT/facility data – managed by the federal government (e.g., VA data). These data sources are preferable to retrospective flat files or Blue Button data. The essential data set to manage under risk is a full source of clinical data (e.g., USCDI Core elements and their evolution), claims and cost data of aligned patients, a provider directory of those participating in the network, and member/patient identity. Historical HL7 transactions, such as ADTs and other patient monitoring transactions, are also necessary. For an ACO with practices across various EMRs to support its participants as an extension of the physicians, it is important to incorporate scheduling and appointment data into the USCDI Core elements. This addition will help eliminate barriers to patient care coordination, reduce provider burden, and enhance patient engagement.
ACOs also face issues with beneficiaries opting out of data sharing, as it is challenging to effectively manage patient care with limited claims history. We encourage CMS to consider ways to either require data sharing as a condition of participation or exclude those beneficiaries from certain programs to hold ACOs harmless.
The Honorable Administrator Mehmet Oz, M.D.
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244
Dr. Thomas Keane
National Coordinator for Health Information Technology
Department of Health and Human Services
330 C Street, S.W., Mail Stop: 7033A
Washington, DC 20201
June 15, 2026
Re: Interoperability Standards and Prior Authorization for Drugs Proposed Rule (CMS-0062-P; RIN: 0938-AV44)
Dear Administrator Oz and Dr. Keane:
Thank you for the opportunity to provide comments in response to the Request for Information (RFI) on Electronic Event Notifications for Value-Based Care and Care Coordination included in the Interoperability Standards and Prior Authorization for Drugs
Proposed Rule.
Accountable for Health is a non-partisan, national advocacy and policy organization accelerating the adoption of effective accountable care. We aim to support policymakers to advance the movement in the health care system toward accountable care that achieves better outcomes, improved care experiences, increased access, and lower costs.
Data is foundational to success in accountable care arrangements, and few data sources are more important than timely access to admission, discharge, and transfer (ADT) notifications. Accountable care providers cannot effectively manage quality and total cost of care if they do not know when an aligned beneficiary has been hospitalized, discharged, or treated in the emergency department. Real-time ADT notifications allow providers to serve as the “quarterback” of a patient’s care by initiating timely follow-up, reconciling medications, coordinating with specialists and post-acute providers, and addressing issues before they result in another emergency department visit or
readmission.
Since May 2021, CMS has required hospitals to electronically notify a patient’s established providers of admission, discharge, and transfer events (42 CFR 482.24(d)). In practice, however, accountable care organizations (ACOs) bearing financial accountability for total cost of care often struggle to receive these notifications reliably, completely, or in time to intervene. Our members face a range of barriers that can be grouped into the following three categories:
connection is a custom build. This is unsustainable at scale and creates significant barriers to achieving comprehensive beneficiary coverage.
different standards, contracts, and pricing. Smaller and newer ACOs face disproportionate barriers to establishing comprehensive coverage across their aligned populations.
Taken together, these barriers mean that the CoP requirement, while meaningful in intent, has not delivered consistent and reliable ADT notification flows to the accountable care entities that need them most. Our responses to specific questions of the RFI are below.
RFI Questions
What additional information should be included in patient event notifications, beyond the minimum set of information that hospitals are currently required to send (patient name, treating practitioner name, and sending institution name), for more effective and useful patient event notifications to better support transitions of care?
The current minimum data set, limited to patient name, treating practitioner name, and sending institution name, is insufficient to support the care coordination activities for which ACOs rely on ADT information. Based on the operational experience of our members, the
following fields should be required in all ACO-directed ADT notifications: patient demographics, admission/discharge/transfer type, admitting diagnosis, attending physician, discharge disposition, and payer information. Approximately 60% of ADT messages received by our members are missing one or more of these critical fields, and there is currently no enforcement mechanism for data completeness. CMS should define and enforce this minimum data set for all ACO-directed ADT notifications.
What are the challenges with standardizing patient event notifications?
Standardization of ADT notifications has proven difficult for several interconnected reasons. There is no industry-standard data file specification, resulting in significant inconsistencies in what hospitals send, how they encode it, and what fields they include. Every interface requires customization. Even hospitals using the same underlying EHR platform configure their instances differently, meaning that a connection built for one hospital does not transfer cleanly to another. The operational cost of managing this fragmentation falls disproportionately on ACOs. Currently, the ACO bears the cost of aggregating, cleaning, deduplicating, and finding the signal within the data that is being sent. For organizations operating across dozens of states and managing connections with numerous vendors and HIEs simultaneously, this represents a significant share of total organizational resources, including both engineering staff and non-clinical care coordinators dedicated to reconciling conflicting information. For a family or independent practice, the operational and financial burden makes this effectively out of reach entirely.
A related standardization challenge is the role of EHRs in the notification ecosystem. While some EHR platforms may surface ADT data through their closed systems, this data is accessible only as a point-of-care, transactional view. It cannot be extracted to a data warehouse, queried systematically, or used in population-level workflows. It stays within an isolated area of the EHR and is not available for the downstream analytics and care management functions that ACOs depend on, including monitoring admission trends in near real time, running leading KPI dashboards, and supporting central care management teams that scan across the full attributed population for patients requiring follow-up.
Policies that push standardization through EHR certification without explicitly requiring data extractability risk moving ADT data from accessible aggregated feeds into EHR silos where it is technically present but operationally inaccessible.
On roster-based matching, CMS should define a standard roster file format, building on existing BAR file structures, and require Medicare-participating hospitals to accept and process ACO patient rosters for ADT alerting. The ability to submit an attributed patient list and receive notifications for all patients on that list is, in our members’ experience, virtually nonexistent at scale. A national standard eliminates the current patchwork of custom builds and is the single most important structural change needed to make the CoP work as intended for accountable care entities.
How are ACOs or payers that are currently receiving patient event notifications receiving them? What innovative strategies have ACOs or payers employed to receive patient event notifications? Do ACOs or payers that receive patient event notifications use the information in a meaningful way?
A4H members use ADT event notifications extensively and derive meaningful clinical and operational value from them. Timely ADT data enables proactive discharge planning and care coordination, including scheduling PCP follow-up within three days of discharge; real-time performance tracking, including monitoring admission and readmission trends before claims data is available; population-level surveillance, such as detecting spikes in condition-specific admissions during high-acuity periods; and support for central care management teams who scan for high-risk patients requiring follow-up across a full attributed population. Quality measures tied to post-discharge follow-up are directly and measurably affected when notifications are absent or delayed. Where members do not receive timely notifications, timely follow-up is not possible, and this creates a ripple effect across outcomes and quality scores.
To receive ADT notifications today, our members have built layered infrastructure drawing on multiple source types simultaneously. Health Information Exchanges (HIEs), both national and regional, accessed via Carequality and regional exchange networks, provide broad coverage but with significant variation in timeliness and data completeness depending on how individual hospitals are configured. Third-party vendors consolidate feeds from multiple hospital systems and can approach 80% national coverage but introduce latency typically up to 72 hours and have gaps where hospitals or post-acute facilities do not publish to these networks. For high-volume health system partners, some members maintain direct point-to-point HL7v2 ADT integrations, which are the most reliable and real-time but require significant technical investment and ongoing relationship management with each individual facility. The scale of this infrastructure investment means that for an independent or solo practice, in our members’ experience, it is effectively out of reach.
Across these sources, our members receive ADT notifications for approximately 60–80% of their attributed patient populations, with wide variance by market. Some markets particularly where a mature state HIE or dominant aggregator has achieved broad participation that approaches 90% coverage. Others fall as low as 30–40%, typically where a large health system has not connected or state HIE infrastructure is underfunded or technically dated. We recommend that CMS prioritize policies that strengthen HIE infrastructure by making HIEs more open, stable, and capable, alongside requirements for hospital participation in HIEs and national aggregator networks.
What actions should CMS consider, such as updating the hospital CoP, that would encourage or require hospitals to exchange alerts with any ACO and other PAC provider and supplier types or payers to which a patient is attributed or assigned?
CMS should maintain and strengthen current requirements related to event notifications and move from a flexible, guidance-based approach toward enforceable standards with clear compliance expectations. Several specific, near-term actions could include:
What processes are in place for attribution and patient matching between hospitals and ACOs or other value-based care arrangements, payers, PAC facilities, longterm care facilities, social service providers, EMS providers, behavioral health providers, etc.? Are these adequate? What is missing from these processes?
Attribution and patient matching between hospitals and ACOs is one of the most significant operational gaps in the current ADT ecosystem, and existing processes are inadequate.
The most functional approach our members have implemented is a roster-based model, in which lists of attributed beneficiaries are transmitted to hospitals and aggregators so they can alert the ACO when those patients present in the emergency department (ED), are admitted, or are discharged. However, only approximately 40% of hospitals accommodate this approach. Larger health systems with mature IT infrastructure are more likely to support it; smaller community hospitals and critical access hospitals frequently lack the technical capability or operational bandwidth to ingest and match against external rosters.
Where roster-based matching does exist, there is no standard format or submission process. Every hospital requires something different, including different file formats, different transmission methods ranging from SFTP to portal upload to fax, and different refresh cadences. For an organization operating nationally across multiple markets, this creates an enormous administrative burden, and the absence of a national standard means every new hospital relationship requires a custom build from scratch.
For hospitals that do not accommodate rosters, matching depends entirely on the hospital independently identifying a patient’s established provider at the point of care, a process that is inconsistent and frequently fails when attribution data is not current. This is compounded by the fact that notifications typically originate from EHR scheduling systems, but large health systems heavily host and configure their EHR instances, meaning ACOs cannot go directly to the EHR vendor and must instead work through each hospital’s individual technical staff.
The consequences of these attribution and matching inconsistencies compound the existing timeliness and completeness gaps. Timeliness suffers because notifications that depend on manual or inconsistent matching frequently arrive hours or even days after the triggering event, well past the window for meaningful intervention. For ED treat-andrelease events, notifications often arrive after the patient has already left the facility. There is also a signal-to-noise problem: alerts fire for every patient movement within the hospital, and care coordinators must track patients moving from the ED to imaging to the surgical suite and back, making it difficult to identify the events that actually require action.
The gap extends beyond hospitals entirely. Post-acute facilities, including skilled nursing facilities and home health agencies, are not currently required to send ADT notifications, leaving ACOs without visibility during a critical phase of care transition. The requirement should be extended to these settings.
We recommend that CMS should define a standard roster file format (building on existing BAR file structures) and require Medicare-participating hospitals to accept and process ACO patient rosters for ADT alerting. A national standard eliminates the current patchwork.
What technical approach(es) would provide additional functionality/ value to the patient event notification process?
Accountable care entities benefit from data sources – including clinical data, charge data, claims data and HIE/ADT/facility data – managed by the federal government (e.g., VA data). These data sources are preferable to retrospective flat files or Blue Button data. The essential data set to manage under risk is a full source of clinical data (e.g., USCDI Core elements and their evolution), claims and cost data of aligned patients, a provider directory of those participating in the network, and member/patient identity. Historical HL7 transactions, such as ADTs and other patient monitoring transactions, are also necessary. For an ACO with practices across various EMRs to support its participants as an extension of the physicians, it is important to incorporate scheduling and appointment data into the USCDI Core elements. This addition will help eliminate barriers to patient care coordination, reduce provider burden, and enhance patient engagement.
ACOs also face issues with beneficiaries opting out of data sharing, as it is challenging to effectively manage patient care with limited claims history. We encourage CMS to consider ways to either require data sharing as a condition of participation or exclude those beneficiaries from certain programs to hold ACOs harmless.
Conclusion
A4H appreciates the opportunity to provide comments on this RFI. If you have any questions about our comments or need more information, please do not hesitate to contact Mara McDermott, mmcdermott@accountableforhealth.org.
Sincerely,
Mara McDermott
CEO
Accountable for Health
Share
Related Posts
A4H File Comments on the Patients First Act Request for Information
A4H files comments in response to the Request for Information (RFI) on the Patients First Act. A4H supports the goal to establish a stable, predictable Medicare physician payment system and believes those reforms should be paired with policies that address the underlying drivers of Medicare spending.
A4H Statement on House Passage of the Health Care Efficiency Through Flexibility Act
A4H sent a letter to congressional leaders supporting H.R. 5347, the Health Care Efficiency Through Flexibility Act, praising the bill as a practical step to reduce unnecessary administrative burden on ACOs, preserve quality reporting flexibility through 2029, and support continued participation in value-based care.
A4H Response to the FY 2027 Hospital Inpatient Prospective Payment System Proposed Rule
A4H files comments in response to the Fiscal Year (FY) 2027 Hospital Inpatient Prospective Payment System (IPPS) proposed rule, specifically the Comprehensive Care for Joint Replacement Expanded (CJR-X) Model and the Transforming Episode Accountability Model (TEAM).