Edifecs Solution Addresses New CMS Prior Authorization and Interoperability Mandate

Best in KLAS solution for CMS-0057-F already in market and available now

Edifecs, Inc., a global health information technology solutions company, announced today that its market leading healthcare interoperability solution now includes proven and production-ready capabilities that enable customers to comply with the recently published Centers for Medicare & Medicaid Services’ (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F). The two-time Best in KLAS award winning Edifecs interoperability solution includes its EDI and FHIR Gateways, which have been enhanced to address the provisions in the new Rule, including Prior Authorization and Provider Access APIs.

In anticipation of the final rule, Edifecs has worked with customers, including a large regional Blues organization, to build a robust interoperability solution that expedites prior authorization, alleviating much of the manual effort and administrative burden. The Edifecs solution, which has been in use since last Fall provides its customers with the opportunity for a substantial head start on CMS-0057-F compliance.

CMS-0057-F is expected to significantly simplify prior authorization and facilitate data exchange across the healthcare system resulting in decreased administration cost and improved patient experience. According to CMS, implementation of the provisions in CMS-0057-F will result in cost savings of approximately $15 billion over the next 10 years through increased efficiencies. The rule builds upon the Interoperability and Patient Access Final Rule (CMS-9115-F), adding the requirement to share clinical, claims, and encounter data for any encounter including prior authorization data or requests.

“We commend CMS for passing the final rule. The rule will significantly expedite interoperability across the healthcare market. Our industry is plagued with data blocking and there is a lack of data coordination between payers and providers,” said Venkat Kavarthapu, CEO of Edifecs. “Edifecs has a near 30-year legacy of helping our customers comply with regulations including HIPAA, the ICD-10 transition, operating rules, the Interoperability and Patient Access Final Rule, the No Surprises Act, the Burden Reduction Initiative, and 39 state-specific encounter submission modules. Edifecs’ decades of experience empower payers and providers to take a strategic approach to compliance. Instead of ticking a box, our customers use compliance to improve their value proposition and achieve competitive differentiation to increase their market leadership,” continued Kavarthapu.

CMS-0057-F expands the required APIs payers must maintain in support of interoperability to ensure continuation of care and reduce delays in care due to lack of clinical history. The key elements to the new rule include:

• Payers are required to share data about prior authorization status and decisions through an HL7 FHIR-based API and must report on API usage.
• Payers are required to share member data with in-network providers treating those members via a FHIR Provider Access API if the provider requests the data. Payers must also share data with other payers covering that member via a FHIR Payer-to-Payer API.
• The rule mandates the adoption of electronic prior authorization processes using a Prior Authorization API. It also requires authorization decisions within defined, narrow windows, and public reporting of metrics about authorizations.
• There is also a longitudinal health record implication to the rule for aggregated data sharing across both payers and providers.

The Edifecs EDI and FHIR Gateways enabled with the Prior Authorization API are designed to scale and address complexity targeted by CMS-0057-F. The modular solution offers continuous compliance. Edifecs’ data integration capabilities meet the mandate’s hybrid deployment requirements and are built to integrate with any backend system. Additionally, Edifecs offers policy management, automation, and approval policies that turn compliance into a strategic advantage.

“The potential benefits of the Prior Authorization and Interoperability mandate extend beyond what CMS projects – increased efficiency, burden reduction, and patient empowerment,” stated Chris Lance, chief product officer, Edifecs. “Organizations that make a strategic investment in FHIR and longitudinal health records can create member transparency and trust. They can also provide their internal teams with a richer source of data for managing populations and machine learning, adopting alternative payment models, and driving down chronic care management costs.”

Edifecs, its customer HCSC, and HL7 will be co-presenting in a Spotlight Theatre session at HIMSS sharing advice on Consent Management and how to strategically approach CMS-0057-F compliance on Wednesday, March 13 at 1:45pm ET.

To learn more about the Edifecs solution, visit https://www.edifecs.com/products/cms-0057-f

About Edifecs

Edifecs provides market leading technology to its payer and health system customers, which serve nearly 300 million people in the U.S. healthcare market. For over 25 years, Edifecs has enabled customers to unlock greater value by aggregating, normalizing, and unifying data with its Best in KLAS interoperability platform. The Edifecs platform serves as the foundation for the solutions that eliminate stakeholder friction to overcome healthcare’s biggest challenges, including accelerating value-based payment adoption and obtaining more complete and accurate care funding for alternative payment models. Edifecs’ solutions incorporate natural language processing, machine learning, and artificial intelligence to provide deeper insights into patients, populations, and business processes. As new standards and regulations continually emerge from government agencies, Edifecs is a proven partner to ensure its customers maintain “evergreen” compliance. Edifecs customers include 24 of the 25 top commercial health plans in the country, 27 out of 34 of the Blue Cross Blue Shield payers, 35 of the 50 Medicaid programs, and 5 out of 10 of the largest health systems.

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