Are You Ready for CMS-0057-F?

Innovation Opportunities Along the Timeline

Data Modernization

• FHIR^®-native APIs versus Facade FHIR APIs
  Facade FHIR APIs require significant layers of mapping and integration with multiple legacy data sources. FHIR-native systems offer transformation and FHIR data at the core, with seamless interoperability, faster data access, ease of scalability and future-proofed compliance. Adapting to new or evolving regulations and IGs is more efficient with FHIR-native APIs.
• Transitioning from X12 to FHIR
  While the CMS-0057-F mandate allows data to be processed and stored in X12, a system-wide conversion into FHIR has short and long-term benefits. Standardizing all data into FHIR unifies data-sets into a single cloud repository with less risk of duplication and siloed information. FHIR is the globally adopted standard for interoperability, and it is the direction that healthcare is evolving. 

Innovate with CQL

CQL (Clinical Quality Language) is a valuable tool for expressing clinical decision-making and quality measures, particularly in areas like prior authorization processes. While it is not yet a requirement of the CMS mandates, it is highly recommended as part of the Da Vinci Documentation Templates and Rules (DTR) Implementation Guide (IG).

Utilizing CQL promotes consistent interpretation of rules, and can dynamically adjust questionnaires based on available patient data. The FHIR & CQL technology refines the precision and effectiveness of PA decisions by ensuring adherence to clinical standards. Learn how to realize the benefits of Smile’s FHIR and CQL engine here.

• Automated Prior Authorization with Computable CPGs
  Deliver PA approvals in real-time at the point of care, to elevate Payer-Provider relationships and patient satisfaction. Calculate your network-wide savings from fully automating your PriorAuth workflows. Authoring payer policies using FHIR & CQL provides significant return on investment on the single Smile Platform; this can unleash deterministic system processed adjudication to reduce payer’s administrative burden.
• Deterministic AI to accelerate Computable CPGs (FHIR+CQL)
  Most PA automations in the market today are based on the probabilistic AI approach, which assigns likelihoods to potential outcomes. Smile has AI tooling to accelerate the authoring of Payer Policies into FHIR+CQL to support an 100% accurate deterministric approach. Learn about how Smile’s solution resolves systemic PA denials in our blog.