Implementing CMS-0057-F, which mandates using FHIR APIs for prior authorization (PA) workflows, is a critical step forward in streamlining administrative processes and reducing provider burden. While the requirement to adopt FHIR APIs—specifically the CRD (Clinical Request for Data), DTR (Documentation Templates and Rules), and PAS (Prior Authorization Support)—is a well-publicized aspect of the rule, it’s essential to understand that this is just the tip of the iceberg.
In reality, aligning with the requirements of CMS-0057-F requires a much deeper understanding and technical infrastructure to ensure these APIs function seamlessly within the larger PA workflow.
As health plans look to implement CMS-0057-F and leverage FHIR APIs for PA workflows, they must address several critical complexities beneath these initial requirements.
While the rule introduces new requirements, it also allows health plans to streamline operations, improve collaboration with providers, and better align care with clinical best practices.
Let’s break these down into key areas of concern:
Integrations with utilization management (UM) and external system endpoints
For FHIR APIs to work effectively, health plans must integrate them with existing applications, such as the UM system, many of which are siloed or not directly FHIR compliant. The UM and other external system endpoints must connect through the workflow.
These systems may involve different data formats, technologies, or operational procedures, requiring intricate integration strategies to ensure smooth data exchanges.
A successful integration must account for various clinical, data aggregation, and operational needs to facilitate prior authorization workflows. Failure to do so may result in incomplete workflows, delayed decisions, or administrative errors that undermine the goal of reducing provider burden.
Routing auths to external delegated vendors
Although the CMS rule does not specifically address this issue, health plans often delegate certain authorization requests to various external vendor partners, adding another layer of complexity. Ensuring the FHIR API appropriately communicates and transfers data between internal systems and external vendors requires careful coordination.
This requires:
- Understanding the vendor’s system requirements
- Ensuring that both systems can understand each other’s data formats
- Validating and confirming that the external vendor has received the correct data and can respond promptly
Improper handling or missed connections at this stage can derail the entire PA process and create significant delays.
Configuring and reconfiguring requirements based on member and procedure information
Every PA request is unique, and the required data fields vary significantly depending on the member’s eligibility, procedure code, diagnosis code, place of service, and provider information. To effectively configure these requests at scale, health plans must ensure that they have dynamic and flexible systems capable of adapting to each request.
As member eligibility or health plan policies change, the system CRD workflow must adjust to accommodate each policy’s evolving requirements. Failure to accurately adjust to variable and frequently shifting requirements can lead to incorrect authorizations or denials.
Medical policy digitization and ongoing management
Medical policies must be digitized and continuously managed to enable the submission of clinical documentation via the FHIR APIs. This process involves converting existing paper-based medical policies into digital formats and mapping them to relevant procedure codes so they can feed requirements through the APIs to enable a smooth authorization workflow.
Ongoing management of these policies is particularly challenging, with medical policies frequently adapting to organizational policy and new clinical information, treatments, and technologies that emerge regularly. Therefore, health plans require an agile approach to updating medical policies within their digital infrastructure.
FHIR app/interface creation for documentation collection
One key aspect of the DTR API is its ability to facilitate the collection of medical necessity documentation from providers. However, the CMS rule does not mention the necessity of creating an intuitive FHIR application or interface to facilitate the DTR workflow.
The application must be easy for providers to use and ensure that the documentation collected is complete, accurate, and compliant with medical policies and other regulatory requirements. A poorly designed interface can result in incomplete documentation, delayed approvals, and increased provider frustration.
Health plan clinical documentation gathering
Medical necessity questionnaires are often used in the PA process when advanced clinical evidence extraction systems are unavailable, as they help determine whether a requested service or treatment meets clinical guidelines.
Within the DTR workflow, health plans have two potential options for interpreting and implementing the documentation requirements:
- Option A: Surface the documentation requirements, collect documentation as attachments, and use FHIR attachment submission to collect the clinical information needed to evaluate medical necessity
- Option B: Present medical necessity questions to the submitting provider in a back-and-forth Q&A format, requiring the creation of a logic tree and interface functionality to facilitate replies
At Cohere, we recommend Option A because it reduces provider burden by eliminating the need for the submitting provider to respond to a series of medical necessity questions instead of gathering that information directly from the source documentation. Additionally, we have found that the auth submitter may not always be the best qualified or have direct knowledge of the case to answer complex clinical questions completely and accurately.
Cohere Connect aligns with Option A by surfacing the documentation requirements via a SMART on FHIR app or DTR API, efficiently collecting clinical data in unstructured attachments through an FHIR-compliant endpoint and evaluating the relevant clinical indications using advanced clinical intelligence.
However, Cohere also fully supports health plans with workflows built on clinical assessment questionnaires. This option requires additional digitization work to convert questionnaires into a dynamic Q&A experience. It often requires further scoping and technical features, and health plans should evaluate the impact on workflow efficiency and user experience.
Maintaining APIs in alignment with evolving Implementation Guides (IGs)
FHIR standards and Da Vinci® IGs are evolving and maturing as they accommodate new clinical practices, technologies, and regulatory requirements. While these are the standards to follow, they are not yet fully fleshed out. Because of this, health plans must stay closely connected to the process to ensure their APIs align with the latest, maturing standards.
The only way to truly keep up with these evolving guides is to participate directly in the Da Vinci Project, the industry authority on implementing FHIR APIs. Health plans must allocate the necessary internal resources to maintain their systems and APIs compliant with these changes. This includes having team members with expertise in both day-to-day workflows and technical specifications to ensure that APIs are functioning as intended. Staying on top of these updates is crucial to maintaining compliance with CMS-0057-F requirements. Still, it can be time-consuming and prohibitively resource-intensive for health plans trying to do it alone.
Your CMS-0057-F compliance solution: Cohere Connect™
While adopting FHIR APIs is a critical first step, health plans must go beyond this initial integration to address operational complexities and ensure a seamless PA workflow.
This is where Cohere Connect™ comes in.
Cohere Connect offers health plans a robust solution to meet CMS-0057-F compliance requirements. We leverage FHIR APIs already in use and support health plan operations today. Our solution reduces provider burden and drives interoperability across prior authorization workflows, allowing providers to submit requests easily without calls or faxes. Over six million authorizations* have run through Cohere’s APIs, giving you a scalable and reliable solution for your compliance needs.
Key Features of Cohere Connect:
- Compliance with CMS-0057-F: Supports the required FHIR APIs—CRD, DTR, and PAS—ensuring compliance with the CMS Interoperability and Prior Authorization Final Rule
- Automated Provider Guidance: Provides dynamic, API-based prompts that guide providers to submit the correct information upfront, ensuring smoother workflows and reduced errors
- Streamlined Policy Management: Leverages our PA automation expertise to simplify policy management by digitizing and managing medical policies, ensuring they are current and compliant
- Effective Data Aggregation: Consolidates and centralizes data from multiple sources to streamline workflows and reduce administrative complexity
- Flexible Vendor Support: Easily integrates and routes PA requests to multiple vendors, seamlessly supporting internal and external systems
Partner with UM Experts
PA experts developed Cohere Connect to be configurable and adaptable, supporting changing policies and member requirements.
By partnering with Cohere, health plans can:
- Deliver streamlined submissions: Avoid long lists of questions by automatically collecting information from existing data sources
- Save on administrative costs: Efficiently route requests across multiple vendors or teams, reducing manual intervention
- Gain flexible policy support: Cohere Connect works with various policies, including CMS, industry guidelines, and health plan custom policies
- Improve provider experience: By reducing administrative burdens, providers can focus more on patient care, improving efficiency and satisfaction. With a 93% satisfaction rating+ from our existing clients, our solutions can simplify workflows and enhance provider interactions with health plans
The Time to Act Is Now
Aligning with the requirements of CMS-0057-F is no small feat. While adopting FHIR APIs is essential, the complexities beneath the surface require careful attention to system integrations, data management, and policy digitization. Cohere Connect is here to help you navigate these challenges and ensure compliance with CMS-0057-F.
Discover how Cohere Connect can assist with your CMS-0057-F compliance efforts here.
*Based on Cohere Health data as of Q4 2024.
+Our 93% satisfaction rating is based on feedback from our existing offerings as of Q4 2024 and is not specific to this product.
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About the Author: Matt Parker
