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 have been pended while use case Members continue to work diligently towards Piloting.
We do anticipate having a 2023 Year in Review Public Call in December 2023 - date TBD. Stay tuned.
Please reach out to Use Case Coordinator, Kim Boyd (firstname.lastname@example.org) to obtain updates.
- 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.
- 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.
|Discovery||Use 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.
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
|Execution||Use Case Moved to Execution Phase in November 2022|
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.
Progressing towards Oct 2023 POC 3.0 DELAYED to December 2023 - see 10.11.23 Member call discussions and key takeaways
June 2023 POC 2.0 Successful COMPLETE
Prior Authorization Pilot
|As of January 2023 - Target 1st Live Pilot in Q3/Q4 2024|
Execution Phase Quick Links
Planning Phase Quick Links
Discovery Phase Quick Links
Member Call Discussions and Key Takeaways
|Date||Key Findings and Takeaways||Members Present|
PA team met with RTTD use case members to discuss partnership and workflow process to capture DVH standardized information (will be a 2024 project)
Coordination on upcoming public call presenters and content
Discussed using 270/271 to solve for payer ID challenges
Encourage CodeX UC members to attend Da Vinci work next quarter where they will focus on ID challenges using the 270/271
Created 5 test patients in the EHR test system
Provider NPI and Practitioner NPI now available to the Smart App. Awaiting testing with tech and payer partner
McKesson, US Oncology
PA to present at December Community of Practice meeting
POC 3.0 (Dec 2023) - Update on new data elements in Varian system. Patient member identifier works and queries easily
Once testing is done, create a new list of patients and where we want to enter the information in EHR
Inconsistencies in how health systems, practices enter member is a challenge
Demo for ONC - January 24th
McKesson, US Oncology
November 15th meeting (member cancelled)
Worked on outline for upcoming Dec 13th public call - Year in Review
Co-Founder David Lindsay with Oncora Medical provided demonstration of
Dogwood Health, PMO
Moving towards next steps to POC 3.0; testing new data available in EHR server
Discussed draft of EOY Public Call - tentatively scheduled for Dec 15th. Invitation to be sent out shortly.
POC 3.0 to be delayed to December 2023 (tentatively). Inclusion and testing of more information in the FHIR server is cause for delay
Tentative date set for Year in Review Public call - 12.13.23 at 2pm ET
POC 3.0 progressing, but timeline moved due to need for testing of systems and additional data elements. Expect POC 3.0 in mid November vs. October
POC 3.0 will progress, great that new data will be available. needs to be tested once in the system
Sites confirmed for testing
Preparing for demonstration with CMS/ONC
Anticipating holding a Public Call in December 2023 - Year in Review
EHR will be able to pull in more information but may result in moving POC 3.0
Clinical sites are ready to test
|8.23.23||Discussed informing next version (v5) of USCDI|
Guests from ONC, Evernorth/evicore, Pfizer, Edifecs, McKesson USONC, AMA, USC, Mitre, ASTRO, Telligen, Varian
eviCore, McKesson USONC, AMA, Varian, Mettle Solutions
Evernorth, Varian, ASTRO, Oncora Medical, USONC
Evernorth, McKesson, Edifecs, Pfizer, USC, AMA
|5.31.23||ASTRO, Edifecs, Evernorth, MCG, McKesson, Oncora Medical, USONC, Varian|
|5.3.23||eviCore, Pfizer, McKesson, Oncora Medical, Varian|
|4.19.23||ASTRO, Evernorth, Pfizer, Varian, McKesson|
|4.5.23||Evernorth, eviCore, McKesson, Ontada, Telligen, Edifecs|
|3.22.23||Pfizer, ASTRO, McKesson, EnableCare, Ontada, Evernorth, USONC, Oncora Medical, POCP, Varian, MITRE and Telligen|
|3.8.23||Evernorth, Ontada, McKesson, Varian, ASTRO, USC, Oncora Medical|
|2.22.23||MCG, Telligen, Evernorth, McKesson, ASTRO, POCP, Edifecs|
eviCore/Evernorth, McKesson, Mettle Solutions
|2.8.23||McKesson, Varian, Evernorth/eviCore|
|2.1.23||McKesson, Varian, Evernorth/eviCore|
|1.25.23||McKesson, Telligen, evicore/Evernorth, Varian, USONC, and Pfizer|
|1.18.23||Telligen, McKesson, Varian and Evernorth/eviCore|
|1.11.23||Telligen, Pfizer, ASTRO, McKesson, USONC, eviCore, Edifecs, and Varian|
|1.5.23||Varian, eviCore, McKesson USONC, Telligen|
|12.7.2022||MCG, MITRE, eviCore, McKesson, Telligen|
|11.30.2022||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
- July 25, 2023
- September 26, 2023
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 (email@example.com) to be added to the invitation and received updates and modifications to call schedules.
Use Case Team
|Use Case Coordinator||Kim Boyd||Point-of-Care Partnersfirstname.lastname@example.org|
|Clinical Coordinator||Dr. Liz Canzone||The MITRE Corporation|
|Deputy Program Manager||Michele Galioto, RN||Point-of-Care Partners|
|Technical Lead||Rob Dingwell||The MITRE Corporation|
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