Claims attachments go digital after 30 years 

Healthcare turned digital records into faxes for 30 years. CMS just called time.

Every few years, someone in healthcare declares the fax machine dead. And every few years, the fax machine survives — because no one has built the standard to replace it. Claims attachments are the case in point. A claim goes out electronically. The health plan requests additional documentation, from clinical notes to lab results to diagnostic imaging. And then someone at the practice pulls those records from an EHR, prints them, and faxes or mails them to the payer. Despite widespread EHR adoption, claims attachments have remained largely manual, relying on fax, mail, and portal-based workarounds. On March 20, CMS finalized a rule that changes that — establishing the first HIPAA-adopted national standards for electronically exchanging clinical documentation that supports health care claims.

At athenahealth, we submit more than 327 million claims annually on behalf of the physicians and practices we serve. We also receive and process approximately 20 million documents every month, often arriving via fax. We see this cycle play out at scale — and we know where the cost lands. Not on the large health systems with dedicated revenue cycle teams who can absorb the inefficiency, but on the three-physician family practice where the office manager is also the billing coordinator, on the small specialty group that loses an hour of staff time chasing a single attachment through a fax workflow. Independent and small-group practices bear this burden disproportionately because they do not have the IT resources to engineer workarounds on their own. CMS projects roughly $781 million in annualized savings once the standards are fully adopted — savings that reflect real operational cost, the labor hours consumed by printing, scanning, faxing, mailing, and re-keying documents that should move in seconds.

Congress first identified claims attachments as a transaction requiring a HIPAA standard in 1996. The Affordable Care Act reinforced that requirement. CMS proposed a rule in 2022 and finalized it this spring. Three decades is a long time to wait — and the delay had consequences. Without a federal standard, payers had no universal obligation to accept electronic attachments. Without that obligation, technology vendors had no consistent target to build toward. And without consistent technology, practices kept faxing. Electronic exchange could always work, but no one had required it to.

That pattern should sound familiar to anyone following the broader interoperability conversation in healthcare. The barriers to standards-based data exchange are rarely technical. The tools have existed for years. What has been missing — for claims attachments, for clinical data sharing, for the administrative infrastructure connecting payers and providers — is the combination of federal standards and the will to use them. Frameworks like TEFCA are building that infrastructure for clinical interoperability. This rule extends the same logic to the revenue cycle, bringing one of the most stubborn holdouts in healthcare administration into the standards-based trajectory the rest of the industry is moving toward.

CMS also made a disciplined scoping decision. The proposed rule would have covered both claims and prior authorization attachments. Stakeholders raised concerns about potential conflicts with CMS's own interoperability and prior authorization rule. CMS listened and narrowed the final rule to claims only, leaving prior authorization for future rulemaking. A narrower rule the industry can implement well is better than a broader one that stalls adoption, and the foundation this rule creates will make the prior authorization piece more achievable when it arrives.

Implementation will not happen on its own. Payers need to build infrastructure to accept standardized electronic attachments at scale. Vendors need to integrate the new standards so the transition is seamless for practice staff. And CMS will need to provide clear guidance for smaller practices without dedicated IT teams to interpret a several-hundred-page final rule. One detail deserves attention: while payers are required to accept electronic attachments, providers are not required to submit them electronically. Adoption on the provider side will depend on how much easier the electronic path is compared to the manual one — and the technology partners who make that transition simple will determine how quickly the rest of the industry follows.

At athenahealth, we have been building toward this shift for some time, and we see this rule as a real opportunity to accelerate the industry's move toward more automated, interoperable revenue cycle processes. We look forward to working with CMS and our payer and provider partners to get this right — so the physicians who have been faxing attachments for three decades can finally stop.