A key aspect of oncology care is the use of oncology clinical pathways to standardize treatment, provide effective treatment option(s), and manage cost of therapy. Health systems or pathway vendors provide the pathway content based on National Comprehensive Cancer Network (NCCN) guidelines.
While an oncology clinical pathway application can present treatment options for ACCEPT or DECLINE decisions, there is no standard interface to transmit the data to payers. As a result, 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 pathway content to view the proposed treatment option. Despite the method, most prior authorization processes among payers rely on manual inspection, with no automation or standard interface to health systems.
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.
Standardized transmission of treatment recommendations from an oncology clinical pathway to the payer allows automation of a large percentage of prior authorization requests. The content of the exchange messages includes mCODE elements, extensions via CodeX elements, acceptance or denial of the recommendation, free text entered by the oncologist and the standard prior authorization claim bundle.
The Oncology Clinical Pathways: Prior Authorization Support use case will provide a standardized transmission of mCODE and CodeX extension oncology data to the payer.
mCODE+ data is transmitted from an oncology clinical pathway to a payer with the intent of automation of prior authorization.
Oncologist has accepted or denied a treatment recommendation.
Oncology clinical pathway navigation to a treatment recommendation for an ACCEPT or DECLINE decision.
The prior authorization request is processed by the payer to approve or decline the treatment recommendation and transmitted as a prior authorization response to the health system’s EHR.
Pathways contain both oncology and clinical data elements that are not in mCODE for branch navigation. These need to be modeled into CodeX elements to be used in pathway navigation.
The health system uses an mCODE-enabled oncology clinical pathway application. The payer implements the standardized process for receiving and processing the prior authorization request.
Intent: Use mCODE/CodeX elements in the oncology clinical pathway and populate the prior authorization request in a standardized way to enable automation of prior authorization approvals and denials.
Inclusion: Clinical concepts and decision support for oncology diseases.
Exclusion: Clinical concepts and decision support for non-oncology diseases.
Clinical data exchange greatly improves payer coordination with health system, enabling value-based payment models.
Oncology Clinical Pathways Fact Sheet