Meeting CMS’s 0057f regulations requires a significant shift in both technical and operational improvements to US health plan prior auth and utilization management infrastructure. CMS is the intending to achieve outcomes beneficial to providers and patients like faster turnaround times and more transparency for denials. Most may not see this as beneficial to health plans. However, although plans are being “regulated” into compliance, we believe the full implementation will lead to a massive reduction in operational burden for health plans, accompanied by fewer errors and more standardization in the prior auth determination process.

Our team at GenHealth has been hard at work with a number of plans and providers to help them meet and leverage the new level of interoperability fostered by these requirements. The burden of implementing the 0057f rule rests on the health plans to support the following actions:

1. Faster turn around times (sometimes as low as 24 hours based on the state)
2. Clear denial reasons
3. Recommended Da Vinci spec FHIR APIs

This guide is intended to support those building APIs to integrate and demonstrate the full utilization management and prior authorization workflow from beginning to end using GenHealth’s UMPA application and APIs.

Da Vinci

The CMS regs recommend (but do not require) that APIs supporting 0057f be FHIR and use the Da Vinci specification. Our implementation and integration guide is geared to adhere to that recommendation. The Da Vinci guides however leave a lot to be imagined and spec’d out. For example see this diagram from the HL7 FHIR documentation and note the part that mentions “all the colored arrow endpoints are potential certification criteria.” There are a lot of colored arrows, and many more that would be behind the scenes of this HL7 implementation guide (IG).

We are attempting to help clarify many of these details in the below diagrams that demonstrate how FHIR servers and other API implementers can meet the last mile with GenHealth’s prior auth policy database and determination engine behind those APIs.

CRD

DTR and PAS