Prior authorization is a pre-approval process where a provider seeks approval from a health plan to initiate a treatment plan or approve a drug for a patient. It involves multiple stakeholders and communication between the provider and the payer, which can result in delays. Balaji Narayanan, SVP of Engineering and Product Development at Onyx, explains the process in this video.

This video talks about electronic prior authorization (ePA), a modern solution to the current prior authorization process, where data is transmitted electronically between providers and payers to get approval in a digitized format. The CMS is releasing regulations to standardize the process, reducing complexity, human intervention, and manual activity.

The challenges with an existing prior authorization process are explained in this video. The lack of standardization across different payers, the time-consuming nature of the process, the need for extensive documentation, and the confusion for patients all add to the complexity. Providers and pharmacists may not be aware of the need for prior authorization until claims are denied. These challenges burden patients, providers, and payers and highlight the need for a modern solution like ePA.

This video explains about the status of Electronic Prior Authorization (ePA) in the healthcare industry. It explains how ePA is being explored by many health plans to improve patients’ health benefits and reduce costs in the prior authorization process. The industry is developing ePA with the help of EMR systems, vendors, and payers invested in HL7 FHIR standards. Work is being coordinated by HL7 through several reference implementations and connector processes to improve the implementation guides.

Learn about the benefits of Electronic Prior Authorization (EPA) in healthcare. The American Medical Association found that delays in prior authorization can lead to serious health problems, including hospitalizations. EPA reduces burden for all stakeholders and can avoid time-consuming manual reviews. EPA provides real-time approval and reduces costs for both payers and providers. Benefits include reducing the burden of documentation, faster decision-making, better results, and better treatment plans for patients

The video explains the first step of an Electronic Prior Authorization process called “Coverage Requirements Discovery (CRD).” CRD is a standard method for providers to check with payers to see if prior authorization is required for a treatment, service, or drug. The CRD implementation guide provides a way to integrate prior authorization queries into the EMR or EHR system, and it defines the information required to determine the decision to approve a prior authorization.

This video explains the 2^nd step of the Electronic Prior Authorization process, which focuses on the documentation template and rules. It defines the specific documents and rules that providers must submit for payers to approve or reject prior authorization requests. The implementation guide standardizes the process across all payer-provider submissions and reduces the provider’s burden by automatically extracting information from the provider’s system.

This video discusses the final step of the electronic prior authorization process called Prior Authorization Support (PAS). The provider submits all documentation and questionnaire responses in a bundle to the payer for a decision. The payer may obtain a waiver to receive the documentation in a different format but must prove their success rate. If the payer cannot decide, the status may be pended for further review.

This video discusses the technical requirements for implementing electronic prior authorization (ePA) for payers. This includes having an identity service that is compliant with the SMART on FHIR technology, integrating with the providers’ system, having a FHIR server for storing structured resources, and CDS Hooks technologies, and whitelisting providers that don’t require prior authorization. Additionally, the payer needs a medical policy guideline that needs to be converted to a SQL library and a questionnaire generator.

This video discusses how Onyx, a SaaS solution provider, can help payers comply with mandates and implement electronic prior authorization. Onyx has accelerators that can expedite development and the core system is built with Microsoft, providing extensible support for multiple custom implementations. Their framework enables rapid customization and compliance with HL 7 Davinci standards. The viewer is encouraged to contact Onyx’s client success team for assistance with their FHIR needs.