X12, HL7’s Da Vinci Project collaborate to improve prior authorization

The standards organizations are working together to set crosswalks between their standards, bringing hope for a transition to automated, real-time determinations.

Two standards organizations are working together more closely in an attempt to accelerate efforts to further automate the “prior authorization” process.

X12 and HL7 are collaborating on the Da Vinci Project, an accelerator program within HL7, to further automate what has been a largely manual administrative process.

For decades, X12 has developed and refined widely used standard formats for electronic data interchange, including claims submission and response, that the Centers for Medicare & Medicaid Services has authorized for use by HIPAA covered entities. More recently, The Da Vinci Project has been building standards for code sets that use the Fast Healthcare Interoperability (FHIR) standard, which is designed to ease the exchange of patient records and other information among organizations.

Both standards development organizations are accredited by the American National Standards Institute.

As a result of tighter collaboration, X12 and HL7 are establishing “crosswalks” connecting the data in FHIR transactions and the data in associated X12 standard transactions. Connecting the two is crucial in facilitating fully automated transactions.

A crosswalk maps the relationships between different data sets and enables stable and reliable translations across the standards. Tying X12 and Da Vinci Project efforts together will give the industry a transition from the X12 batch and manual processes in point-to-point connections available today for prior authorizations to standardized, real-time, automated queries and responses among multiple providers and payers, the partnering organizations say.

In a pioneering effort, a payer and two provider organizations on the West Coast that are Da Vinci Project participants expect to begin using FHIR code sets this summer to exchange prior authorization data.

Importance of the initiative

Prior authorization automation is the focus of several other initiatives now underway to reduce administrative burdens.

Earlier this year, the Office of the National Coordinator for Health Information Exchange sought input on electronic prior authorization standards. Meanwhile, the American Medical Association and AHIP, an association for health plans, are conducting initiatives seeking to improve the process.

Today, seeking prior approval for treatment and reimbursement from insurers often is a highly manual process that involves submitting faxes or using an insurer’s portal to submit data.

"Prior authorization can involve a complex conversation between a provider and a payer, but these emerging standards enable questions to be resolved without human intervention."

Kirk Anderson, vice president and chief technology officer, Cambia Health Solutions

Over the past year, the Da Vinci Project has been working to apply FHIR transactions to prior authorization transactions. It has identified FHIR use cases necessary to automate the process. For example, the standard can be used to make a query of an insurer to see if prior authorization is needed (termed Coverage Requirements Discovery). If such authorization is needed, then FHIR can be used for communication to determine which documentation is required (called Documentation Templates and Rules) and then automate the extractions and communication of needed information (called Prior Authorization Support).

On the X12 side, the 278 standard for EDI sets parameters for healthcare prior authorization requests and responses. But this data is often exchanged in batch mode, not in real time. As a result, the 278 transaction is difficult to use to gain immediate responses while the patient and clinician are interacting during a visit.

The Da Vinci Project and X12 have been working for three years to enable an easy crosswalk between the approaches, says Jocelyn Keegan, program manager for Da Vinci. The latest collaborative efforts are designed to help enable these transactions to be compliant with HIPAA standards and facilitate automation of the prior authorization process.

The collaborative effort takes advantage of HL7’s expertise in standards for clinical data and X12’s focus on administrative transactions, says Cathy Sheppard, X12’s executive director. The organizations are working to enable healthcare organizations to make a gradual transition from X12 transactions to FHIR-based transactions, she adds.

“We expect this to be a complementary process that we can use to enhance what we’re providing to healthcare organizations,” Sheppard adds. “We are working on crosswalks to make sure everyone is using the same connections.”

Initially, HL7 and X12 are focusing on crosswalks to support Da Vinci’s Prior Authorization Support implementation guide, which provides a format for creating FHIR-based messages that contain the data necessary for X12 transactions. Crosswalks contain the specific instructions necessary for those implementing FHIR-based prior authorizations to have a common semantic mapping between the two standards on a data field by data field basis.

Supporting the dialogue

The crosswalk approach can enable adoption of FHIR parallel to legacy approaches for exchanging data in prior authorization exchanges between providers and payers, says Kirk Anderson, vice president and chief technology officer at Portland, Ore.-based Cambia Health Solutions, the parent company of Regence, a Blue Cross/Blue Shield plan.

Kirk Anderson, Cambia Health Solutions

Prior authorization can involve a complex conversation between a provider and a payer, but these emerging standards enable questions to be resolved without human intervention, Anderson says.

“We can get that back-and-forth in real time so we can get that answer sooner; it’s really the benefits from the RESTful APIs that are at the heart of the Da Vinci Project’s work,” he explains (A RESTful API is an interface that two computer systems use to exchange information securely over the internet).

Payers want to find an automated solution that accelerates care delivery for patients and reduces the variability for providers when dealing with the many payers, Anderson says. Moving to a FHIR standard-based approach would enable consistently structured data to flow in machine-readable formats, he adds.

Cambia hopes to soon put the FHIR-based prior authorization process into production with two large provider organizations – MultiCare Connected Care and Oregon Health Sciences University. Cambria worked with the organizations previously to implement Da Vinci-developed FHIR use cases to address other payer-provider data exchange challenges.

Anderson expects the organizations will be able to build “a fully FHIR end-to-end experience. Providers can launch (a prior authorization inquiry) without having to leave their EMR system.”

The prior authorization exchange solution developed by Cambia and the providers eventually could be picked up and used by others, Anderson notes, potentially facilitating any-to-any communication.

“It’s important to understand that all the new API work is additive and will evolve over time,” he says. “As the industry moves to more modern standards that can translate value from existing (technology) investments, it will help us be more nimble over time.”

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