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Real-Time Prior Authorization Coverage Requirements Discovery (CRD) Between a Payer and Provider

October 12, 2023

Denny Brennan, Executive Director and CEO, Massachusetts Health Data Consortium

David Delano, Senior Director of Services, Massachusetts Health Data Consortium

MHDC / NEHEN conducted a prototype electronic automated prior authorization DaVinci compliant CRD (Coverage Requirements Discovery) implementation project with Blue Cross Blue Shield of Massachusetts (BCBSMA) and new England Baptist Hospital (NEBH) to evaluate the feasibility of this solution in a production capacity.

The name of the solution was the ‘FastPass’ Pathways prior authorization workflow. The solution involved the extraction of structured X12 278 (referral) data and unstructured (notes) data from the participating provider EHR systems which then fed into a set of guidelines / recommendations that the system would determine from the data extracted to recommend an authorization, pend or denial from the payer regarding a requested service. The prototype project aimed to enhance that existing set of technologies with a FHIR API capability complaint with the DaVinci implementation guides (IGs) and to evaluate the efficacy of that approach.

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