CMS Review & Response: Evaluating the FHIR Prior Authorization Standard. A WEDI Member Position Advisory (MPA) Event

WEDI Member Position Advisory (MPA) events are exclusive opportunities for WEDI members to provide input on new regulations, policies, and rules that affect the healthcare IT industry. These virtual sessions are used to collaborate on developing WEDI's official feedback to federal agencies like the Centers for Medicare & Medicaid Services (CMS). Recent and upcoming events have focused on topics such as interoperability, prior authorization, and AI in healthcare

CMS will hold a listening session on December 10 to evaluate the FHIR prior authorization standard. This session will be an active discussion on the benefits and challenges associated with implementation of the FHIR API-based prior authorization standard. WEDI and the six Designated Standards Organizations (DSMOs) have been invited to present testimony. Information gathered from WEDI member organizations during the November 17 MPA will be used to form WEDI’s positions and comments for the December listening session.

Event Facilitators:

• Merri-Lee Stine, WEDI Chair
• Denny Brennan, Massachusetts Health Data Consortium, WEDI Chair-Elect
• Janice Bakos, Aetna and WEDI Prior Authorization Subworkgroup Co-Chair
• Samantha Burch, AHIP
• Terry Cunningham, American Hospital Association
• Beth Davis, Veradigm Payerpath
• Raj Godavarthi, MCG and WEDI Prior Authorization Subworkgroup Co-Chair
• Alix Goss, Point of Care Partners
• Gail Kocher, Blue Cross Blue Shield Association
• Michael Lunzer, Itiliti Health and WEDI Prior Authorization Subworkgroup Co-Chair
• Heather McComas, American Medical Association and WEDI Prior Authorization Subworkgroup Co-Chair
• Cathy Sheppard, X12

CMS Questions:

1. To what extent do you believe the use of a FHIR standard for prior authorization will cause a decrease in the use of payor portals, which permit providers to enter data directly into the payors system?
2. Do you have any feedback regarding how to implement a FHIR standard and any subsequent version updates? 
3. Do you have any feedback on the use of CDEX and how it can be used to accommodate prior authorization attachments?
4. What impact do you anticipate the use of a FHIR prior authorization standard having on the cost of providing and paying for health care?
5. What benefits do you see a FHIR prior authorization standard providing? Are there any specific business needs not met by the current EDI standard that a FHIR standard will address?
6. What challenges do you anticipate in moving to a FHIR prior authorization standard?
7. Please share any recommendations or additional information you would like regarding a FHIR prior authorization standard.