The Standard

August Community Roundtable Provides Multi-Faceted View of Prior Authorization Regulatory Requirements and Da Vinci Implementation Resources   

For the August HL7 Da Vinci Project Community Roundtable, industry leaders will offer an insightful, holistic discussion targeting those who want to better understand how best to meet prior authorization regulatory requirements aiming to increase efficiency and improve patient outcomes.   

With a focus on the latest developments surrounding the Da Vinci Prior Authorization Implementation Guides (IGs), the session begins with an examination of clinical and business drivers and a level-setting overview of federal and state level-activities impacting prior authorization requirements. Then we highlight technical standards, focusing on the underlying requirements of CMS-0057,  HTI-4 and the current status of the IGs.  The session concludes with how Da Vinci responds to industry needs, fostering a supportive environment for implementation and providing education, resources, and learnings from real-world implementers and piloting opportunities for those on their implementation journey. 

The U.S. Department of Health and Human Services (HHS), in collaboration with over 45 of the nation’s largest health insurers, has announced an important step forward in transforming the problematic processes of prior authorization. By pledging to reduce delays, increase transparency, and standardize processes by 2027, these organizations have signaled a long-overdue shift toward easing administrative burdens and improving access to evidence-based care.

The pledge spans insurance markets (commercial coverage, Medicare Advantage and Medicaid managed care) and will benefit an impressive 257 million Americans. But turning that vision into reality will require more than declarations. It will demand the kind of trusted technical infrastructure that HL7’s community has built together for over 35 years.

 As implementation begins, prior authorization reform demands scalable, open and consensus-driven standards.

January Roundtable also features Providence’s Clinical Data Exchange Implementation Journey

Are you interested in hearing federal officials provide an overview of the CMS Interoperability and Prior Authorization Final Rule (CMS-0057)?

If so, register now for next week’s HL7 Da Vinci Project Community Roundtable, “CMS Interoperability Final Rule Overview and a Clinical Data Exchange Success Story: How Standardization Improves Value Based Care Performance,” scheduled for Jan. 24 from 4 – 5:30 p.m. ET.

The HL7 Da Vinci Project is thrilled to have CMS join next Wednesday’s Community Roundtable to offer highlights of the final rule in addition to the scheduled program showcasing Providence’s Da Vinci Clinical Data Exchange (CDex) Implementation Guide implementation journey.

Providence became the first major health system to implement CDex standards, and their journey included piloting with Premera Blue Cross and the vetting and approval by internal quality teams and external Healthcare Effectiveness Data and Information Set (HEDIS) auditors. The session concludes with a discussion of benefits experienced using CDex, including improved decision making, reduced burden, improved patient outcomes and enhanced quality of care to patients.

The Da Vinci Project is a private-sector initiative that accelerates the adoption of HL7 FHIR as the standard to support and integrate value-based care (VBC) data exchange across communities. The goal of the project is to help payers and providers positively impact clinical, quality, cost and care management outcomes, enabling providers to see the right data at the right time for patient-centered care.

The presenters will include:

• Lorraine Doo, Senior Policy Advisory,Centers for Medicare & Medicaid Service
• Alex Mugge, Deputy Chief Health Informatics Officer, Centers for Medicare & Medicaid Service
• Semira Singh, Director, Population Health Informatics, Providence  
• Michael Westover, Vice President, Population Health, Providence 

The session will be  moderated by Alix Goss, HL7 Da Vinci Project PMO, and Senior Consultant, Point-of-Care Partners.

Last December, the Centers for Medicaid & Medicare Services (CMS) issued two notices of proposed rulemaking (NPRM) that will greatly influence how FHIR advances.

Da Vinci officially commented March 13 on one the rules, the Advancing Interoperability and Improving Prior Authorization Processes, or “Interop 3,” and submitted comments last week to the other rule, the Attachments NPRM, due on March 20. This rule is a set of HIPAA attachment standards and related definitions for electronic exchange of clinical administrative data to support both prior authorizations and claims adjudication, according to Alix Goss, moderator for the HL7 Da Vinci Project Community Roundtable and HL7 Da Vinci Project PMO, as well as vice president and senior consultant with Imprado.

Da Vinci is not in favor of finalizing the proposed regulations, Goss said. A final rule would require investments across the country that essentially will hardwire the approach making further evolution that much harder and burdensome, and redirecting the industry’s focus, taxing resources.

“Industry payers, providers, clearing houses, vendors, patients and more have to make choices at each step of the interoperability journey, and finalizing these regulations brings complications to the choices already made, and those to come,” Goss said. “We all know that the reality that technology moves faster than policy advancements and we're still working out how to work with this reality.”

Goss advises those who want a deeper dive into these rules to review the January 25 Community Roundtable, where the CMS Office of Burden Reduction and the National Standards group delivered an extensive overview.