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The below depicts the anticipated prior authorization workflow to improve access to care for cancer patients with a focus to leverage the implementation guides developed by the HL7 Da Vinci Accelerator as well as CodeX mCODE. CodeX Use Case members continue to endeavor to partner in operationalize this effort via the current Proof-of-Concept.


Public Use Case Calls are held the last Tuesday of every other month at 3:00 pm EST (subject to change).

Please reach out to Use Case Coordinator, Kim Boyd ( to be added to the public call invitations and to receive updates regarding any changes.

Project Overview


  • Payers vary widely on how prior authorization for cancer therapy is accomplished.  Some use a web portal for oncologists to enter data into an electronic form.  Others use oncology clinical pathways to develop a proposed treatment option. Despite the method, many prior authorization processes among payers rely on manual inspection, with no automation or standard interface to health systems.
  • Prior authorization imposes a burden on patients, providers and payers
  • Current manual processes require duplicate data entry, are costly and may delay treatment 


  • There is national interest, both in industry and the federal government, for standardization of the prior authorization process. The goal is reduction of costs by automation and standardization of health system-to-payer prior authorization interaction.  This has the potential to greatly reduce oncologist burden, which is a known factor in physician burnout.

Target Outcome:

  • Provide a standard method to supplement the Da Vinci Coverage Requirements Discovery (CRD), Document Template Rules (DTR) and Prior Authorization Support (PAS) FHIR-based information exchange framework with cancer specific data as defined by mCODE, to enable prior authorization auto-approvals.
  • Base the solution on approaches referenced in CMS Proposed rules
  • Reduce clinician, health system, patient and payer burden


  • Patients receive timely care without delay because prior authorization turnaround time is reduced
  • Provider burden reduced with automated approvals, and real-time access to payer approval requirements and documentation rules
  • Payer burden is reduced by automating manual processes using a standardized information exchange 


The CodeX Prior Authorization in Oncology are committed to supporting an equitable health care system and have committed to the Federal Moonshot initiative.  

We believe that improving and automating the prior authorization process for patients, providers and payers can result in timely delivery of appropriate and high-quality care.  With timely delivery of care, we can assist in curing and/or prolonging the life of a patient and optimizing the patient’s quality of life.

Commitment #1: Define, model and scaling an automated prior authorization process for cancer patients via the use of FHIR-based healthcare data standards to extract and exchange the necessary information to expedite the prior authorization process for cancer patients and reduce burden for providers and payers. These data standards include the clinical specialty data standards (mCODE representing oncology data, and RTTD representing radiation therapy data) as well the Da Vinci FHIR standards addressing value-based care transactions including those needed for prior authorization. Clinical specialty data standards such as mCODE are essential to ensuring accurate clinical representation for the decision support needed to ensure correlation of the right treatments to the right cancer patients.

Commitment #2: In alignment with industry technical and data standards, modify or create as necessary, open-source technical specification(s) documenting the workflow and criteria necessary to expedite the prior authorization in oncology process.

Commitment #3: Implement the Prior Authorization in Oncology FHIR driven real-time process with point-of-care decision support for stakeholders to assist in expediting care for cancer patients.

Commitment #4:   Capture metrics through this use case in hopes of providing additional insights and learnings that can potentially be applied to informing new best practice in prior authorization in oncology as well as reduction of burden for patients, providers, and payers.

Project Plan




DiscoveryUse case identification  - Breast and Prostate cancer


Proof of Concept

Breast Cancer treatment regimen proof of concept complete - demoed at DaVinci Burden Reduction examples call, and at the April 2021 DaVinci Education and FHIR Implementation Event.

    • Proof of concept for breast cancer and colorectal cancer prior authorization
    • Demonstration of the Da Vinci CRD/DTR/PAS IGs working in a medical oncology flow
    • Test and demonstrate use of adaptive forms in questionnaires to show variations and flexibility of trigger (encounter, order)
    • Document scenarios and open-source code for the questionnaires and CQL



Plan out high level project plan for synthetic environment Proof-of-Concept, deliverables, success measures, high level timeline, key stakeholders, etc.  The focus by use case members is on Prostate cancer PA.

See Project Plan found here - PA in Oncology - Documents


ExecutionUse Case Moved to Execution Phase in November 2022


Phase 1

Radiation Oncology Prior Auth Proof-of-Concept for Prostate Cancer (MVP) with Synthetic Data

Phase 1 include multiple POC Phases to test end-to-end connectivity, use of SMART on FHIR app, POC is in a test environment with synthetic patient and clinical data with defined test scenarios.  This will be replicated in multiple phases.  Then will go to Live Pilot with live patient and clinical data. 

  • Design – Validate workflows, define process and requirements, includes demographic and patient clinical data elements
  • Build & test the exchange of prior authorization between provider and payer systems using EHR test patients
  • Evaluate lessons learned and rescope iteratively
  • Implementation into production environment
  • Use of mCODE data elements in PA transactions
  • Demonstrate PA transactions in the FHIR-based Da Vinci CRD/DTR/PAS information exchange

As of January 2023 - Target 1st Live Pilot in Q3/Q4 2023 - 

Phase 2

Prior Authorization Pilot

  • Scale
  • Advance and apply lessons learned from Phase 1 (MVP)
  • Add additional cancer types
  • Expansion consideration into medical oncology and progress into modality sequencing
    • Potentially health equity
  • Add additional participating organizations (Payer, Provider, Oncology EHR)

Member Call Discussions and Key Takeaways

Execution Phase
DateKey Findings and TakeawaysMembers Present
  • CMS Interop/PA NPRM discussions.  Set up listening session with CMS to discuss oncology nuances
  • RTTD Use case leads joined the call, discussing their progression and potential needs to support PA
  • How to integrate treatment plan to the CRD workflow because now its CPT code based
Pfizer, ASTRO, McKesson, EnableCare, Ontada, Evernorth, USONC, Oncora Medical, POCP, Varian, MITRE and Telligen
  • Technical updates - EHR moving to close gaps on data within their FHIR server to support POC and pilot
  • Initial discussions on medication oncology
  • Getting other payer involved
Evernorth, Ontada, McKesson, Varian, ASTRO, USC, Oncora Medical
  • Initiated discussions on content of learnings from POC and pilot - Whitepaper?
  • Need to get others involved - EHRs, payers, etc. to scale and move to other areas of cancer care
  • Update on technical next steps and potential hurdles
MCG, Telligen, Evernorth, McKesson, ASTRO, POCP, Edifecs
  • Smart on FHIR App tested and working well for CRD process
  • Questionnaires being build for DTR process
  • Continued discussions to understand the potential volume for Pilot 1.0 and the how long to test

eviCore/Evernorth, McKesson, Mettle Solutions

  • Post pilot whitepaper to inform others
McKesson, Varian, Evernorth/eviCore
  • Discussions on volume of patients
  • EHR Validation process
  • Legal requirements for App access to user server
McKesson, Varian, Evernorth/eviCore
  • Members continued review and modifications of the UC Phases to accomplish POC and Pilot
McKesson, Telligen, evicore/Evernorth, Varian, USONC, and Pfizer
  • Technical team members modified wording on phases based on technical processes
  • Discussions continued around what documentation would be needed to support internal approval to Execute on a Live Pilot 
Telligen, McKesson, Varian and Evernorth/eviCore
  • Members confirmed the phases and timing of phases for the POC MVP to Pilot
  • Confirmed the goals of each phase
  • Agreed to have FAH join the next member meeting to discuss PA quality measures
Telligen, Pfizer, ASTRO, McKesson, USONC, eviCore, Edifecs, and Varian
  • Reconfirmed that POC MVP will be multi-phased approach
  • Will begin in Q2 2023
Varian, eviCore, McKesson USONC, Telligen
  • First draft Connectivity Sequencing Documentation (i.e., SMART on FHIR app Launch) reviewed and approved
Varian, eviCore
  • CMS Interoperability and PA rule being released.  Members preparing to respond by March 2023 deadline
  • Draft of technical sequencing documentation progressing
MCG, MITRE, eviCore, McKesson, Telligen
  • Payer, EHR systems successfully connected 
  • Development of SMART on FHIR app in progress
  • Reaffirmed breast cancer is the next synthetic pilot followed by an operational pilot.  Will stay focused on radiation
  • An important consideration before progressing to different treatment methodologies is to expand the pilot pool to include multi-EHR environments
  • Members would like to invite the Office of Burden Reduction and Health Informatics to a December call to update them on POC progression
eviCore, Edifecs, MCG, McKesson and MITRE

Conference Call Schedule & Dial-Ins

CodeX: Oncology Prior Auth Use Case Public Calls 

The Last Tuesday, every other month - 3:00 - 4:00 EST

  • January 31, 2023
  • March 28, 2023
  • May 30, 2023
  • July 25, 2023
  • September 26, 2023

Meeting Details:

Register in advance for this meeting: 

After registering, you will receive a confirmation email containing information about joining the meeting.

Reach out to Kim Boyd ( to be added to the invitation and received updates and modifications to call schedules.  

Use Case Team

Use Case CoordinatorKim BoydPoint-of-Care 
Clinical CoordinatorDr. Liz CanzoneThe MITRE Corporation

Deputy Program ManagerMichele Galioto, RNPoint-of-Care Partners

Terminology CoordinatorTBD

Technical LeadRob DingwellThe MITRE Corporation

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