> Understanding Electronic Prior Authorization The CMS Rule CMS-0057-F mandates that, by January 1, 2027, all CMS-regulated payors must implement electronic Prior Authorization APIs. This advancement is poised to revolutionize healthcare administration, projected to save CMS an impressive $15 billion over the next decade (https://lnkd.in/gai8pJAt). The ripple effect of this mandate is expected to encourage other payors to adopt similar technologies, paving the way for substantial savings for both providers and payors. More importantly, it promises to enhance patient care and alleviate the common frustration faced by both physicians and patients. Electronic Prior Authorization simplifies the approval process: healthcare providers can submit authorization requests digitally, payors can efficiently request necessary patient information from electronic records, and responses—approvals or rejections—are communicated electronically. This not only accelerates the process, enabling authorizations to be completed in minutes rather than days, but also involves patients directly through consumer apps connected to the Patient Access API. This system represents a significant step forward in patient care and operational efficiency, benefiting providers, payors, and patients alike—a true win-win-win scenario. Below is a straightforward diagram illustrating the workflow of Electronic Prior Authorization. It highlights that while we can leverage much of our existing healthcare infrastructure, there are new components, marked with dotted lines, essential for facilitating this digital transformation. Electronic Prior Auth is implemented using the FHIR (https://hl7.org/fhir/) and CQL(https://cql.hl7.org/) standards in healthcare. CQL is the same standard used by HEDIS measures. Using existing standards will help electronic prior auth be adopted faster in healthcare. If you want a more detailed guide, you can see: https://lnkd.in/gEXX6Egs #priorauth #healthcare #cms
josh L.
8mo
If you follow the Da Vinci Burden Reduction IGs, which are likely to be mandatory through CMS policy, the process will look different, and much more complex, than this diagram conveys. The Da Vinci flow is actually broken into three sets of interactions, each with their own required set of FHIR resources, technical standards, and exchange mechanisms. The Da Vinci Burden reduction approach involves the following provider-to-payer interactions: 1.) CRD: Is a prior Auth Needed? 2.) DTR: Is clinical documentation required? 3.) PAS: Prior Authorization Submission and Status Inquery “Provider enters order” is also a bit vague, for example did the provider “select”, “sign”, or “dispatch” the order? The trigger point within the provider system determines the level of information available within the order. Ultimately, payer systems will need enough details to calculate a complete response.
Imran Qureshi Do we know what is the name of the FHIR resource that will be used for Prior Auth Request from the EMR?
Rohit M.
8mo
Very interesting article Imran, at BigRio we are working on Gen. AI based solutions for simplifying the Prior Auth process using FHIR: https://bigr.io/genai-center-of-excellence/
Roman Burdiuzha
8mo
Such an insightful overview of Electronic Prior Authorization and the positive impact it will have on healthcare administration! 💡🏥
Brian Nordberg
8mo
Yikes!
CTO & Chief Data Science Officer at b.well Connected Health
8moFYI- I posted a more detailed version of the electronic prior auth process here: https://www.linkedin.com/posts/imranq2_the-unofficial-guide-to-electronic-prior-activity-7179274779495985152-mQr4?utm_source=share&utm_medium=member_desktop