Prior authorization is a critical healthcare process that often frustrates providers and patients alike. The new CMS Rule 0057 mandates FHIR-based APIs for electronic prior authorization (ePA), creating both compliance requirements and improvement opportunities for health plans. I’ll rewrite this article with SEO-optimized content and provide the requested elements.
Understanding CMS Rule 0057 Requirements
CMS Rule 0057 requires health plans to implement FHIR-based APIs for electronic prior authorization. This shift goes beyond mere compliance – with strategic planning, it presents opportunities for improved member and provider experiences while driving operational efficiency. Drawing from experiences with early adopters, InterSystems addresses five crucial questions health plans should consider.
Connecting Back-Office Systems to FHIR APIs
Successful implementation requires a smart API broker and robust data integration engine. Health plans must access multiple systems to determine prior authorization requirements – from eligibility verification to policy coverage and provider status assessment. Most plans rely on a combination of proprietary medical policies, licensed rules, and third-party vendors for adjudication.
An effective API broker must intelligently route specific requests to appropriate back-office systems. Additionally, since many legacy systems don’t support FHIR natively, a data integration engine becomes essential for normalizing data across systems, enabling smooth bidirectional communication.
Translating Medical Policies Effectively
Rather than attempting to translate all medical policies simultaneously, health plans should prioritize using the 80/20 principle. Prior authorization requests typically cluster around specific procedures – InterSystems’ partners report that a small subset of procedures generates the majority of requests.
By identifying and focusing on these high-volume areas first, plans can maximize ROI while delivering better experiences to more members and providers. This targeted approach reduces the volume of requests requiring costly manual processing while accelerating implementation benefits.
Driving Provider Adoption of ePA
While CMS-0057 requires providers to attempt the new FHIR-based process, consistent utilization depends on positive initial experiences. When change is optional, negative first impressions can significantly hinder adoption of new processes, regardless of subsequent improvements.
Provider education is valuable, but the most critical factor is ensuring your technology works reliably from the start. A solution that demonstrably saves provider time and functions correctly during first use will naturally drive broader adoption.
Scaling to All Lines of Business
Yes, scaling ePA functionality across all lines of business is feasible, provided three key factors are addressed:
- Transaction volume capacity – systems must handle significantly increased queries without reliability issues
- Administrative routing capabilities – your API broker must navigate potentially duplicative systems serving different business lines
- Business-specific prioritization – the subset of medical policies requiring machine-readable translation may vary across lines of business
Leveraging AI for Prior Authorization
AI shows tremendous promise for reducing prior authorization frustrations through streamlining complex processes and identifying systemic bottlenecks. InterSystems is actively developing such applications, but their success depends on high-quality data.
For AI to meaningfully improve prior authorization and advance value-based care, health plans must invest in comprehensive, harmonized data sets that integrate clinical, administrative, and social determinants of health information. These normalized data repositories must remain accessible for multiple use cases to maximize AI effectiveness.
Discover the latest payers’ news updates with a single click. Follow DistilINFO HealthPlan and stay ahead with updates. Join our community today!
