HL7, Cigna & Siemens launch pilot to aid prior authorizations
CodeX is an accelerator group of HL7 working with Cigna and Siemens teams on an automation project designed to speed coverage decisions for patients needing treatment.
CodeX, an HL7 workgroup, is coordinating an initiative that aims to improve data standardization and interoperability to automate and expedite prior authorization for services delivered to oncology patients.
The CodeX accelerator within HL7, which promotes the use of the Fast Healthcare Interoperability Resources (FHIR) standard, is working with Evernorth, the health services business of Cigna Corp., and Varian, a Siemens Healthineers company, on the project.
The FHIR accelerator’s mission is to speed the development of interoperable data modeling and applications to improve patient care and research in oncology, cardiovascular medicine and genomics.
Evernorth and Varian will lead the project focused on radiation oncology that will use FHIR to automate and expedite prior authorization processes between payers and providers.
There is significant interest in improving and expediting the prior authorization process, an often protracted administrative process that is intended to improve patient health, safety and affordability by increasing adherence to evidence-based standards of care. The latest CodeX project aims to leverage FHIR capabilities to expedite the prior authorization process.
Eric Gratias, MD, Chief Medical Officer, eviCore
“We joined CodeX to help drive better communication across the healthcare ecosystem and continue to optimize prior authorization to meet the needs of providers, patients and payers. Advancing health data interoperability is a community effort, and together, we have the opportunity to improve care delivery and outcomes.”
CodeX and the companies involved in this project say it has the potential to reduce costs by automating and standardizing health system-to-payer prior authorization transactions. Such automation could greatly reduce the burden on oncologists and expedite decisions on radiation treatments that are critical in treating cancer patients.
First phase
The first phase of the radiation oncology-focused pilot will concentrate on breast and prostate cancer cases. Participants will build and test the exchange of prior authorization information between payer and provider systems for patients with electronic health records. Once those exchanges are validated, the second phase will test HL7’s minimum Common Oncology Data Elements (mCODE)-enabled prior authorization workflow in a real-world setting and eventually expand it to additional areas of oncology.
CodeX participants say they have high hopes for the automation that FHIR can bring to the communication between providers and payers.
“We joined CodeX to help drive better communication across the healthcare ecosystem and continue to optimize prior authorization to meet the needs of providers, patients and payers,” says Eric Gratias, MD, an oncologist who’s chief medical officer for eviCore, an Evernorth company that manages medical benefits. “Advancing health data interoperability in oncology is a community effort, and together, we have the opportunity to improve cancer care delivery and outcomes.”
Ashley Smith, vice president of oncology information systems and Noona (a patient outcomes management solution) at Varian, notes: “As a cancer care company, one of our main focuses is on finding ways to accelerate the path from diagnosis to treatment. That’s why we’re so enthusiastic about participating in this project – because patients stand to benefit in the future.”
The ultimate benefits
Pilot results will show how providers and payers can apply mCODE-enabled processes to their prior authorization workflows, participants say. Providers and payers ultimately could benefit from more efficient workflows and fewer administrative burdens, and patients could experience more timely access to care and improved treatment outcomes, they say.
Clinicians, payers, prior authorization vendors and radiation oncology specific EHR vendors can still join the pilot project to help shape the standard for how prior authorization is implemented before any regulatory requirements take effect, according to CodeX. More information, including call-in numbers for regular zoom calls, can be found here.