Does Your Digital Prior Authorization Solution Serve All Providers?

With the enforcement date for CMS-0057-F quickly approaching, many Payers are discovering a critical compliance gap: their proprietary Prior Authorization solutions do not serve out-of-network providers. Payers who have turned to proprietary solutions for CMS and Prior authorization compliance, are often only able to support providers on the same system, leaving workflows and adjudication with out-of-network providers at risk of non-compliance.

To avoid paying for and maintaining multiple, fragmented solutions, forward-looking Payers are turning to vendors that offer FHIR-native, EHR-agnostic platforms—designed from the start to align with Da Vinci CRD, DTR, and PAS implementation guides.

The Smile CMS and PA Solution

Smile Digital Health’s CMS and Prior Authorization solutions are built on a FHIR-first platform in alignment with HL7^®Da Vinci Standards for Prior Authorization.

Our solutions are designed to give Payers 100% coverage for both in-network and out-of-network providers within one platform. They are EHR-agnostic, ensuring seamless interoperability across provider systems without requiring providers to adopt or invest in new technology.

The Benefits

Provider Experience
Burdensome PriorAuth workflows remain a topic of friction between Payers and Providers. Smile’s solution streamlines workflows and improves provider satisfaction, without requiring them to invest in redundant integration tools or portals.
Member Experience
Delays caused by fragmented or manual PA processes result in care delays and negative outcomes. A FHIR-native compliance solution helps ensure that all members get timely access to needed care, regardless of whether their providers are in or out of the Payer network.
Payer Experience
There are several benefits for Payers who are considering one solution for their CMS and PriorAuth requirements:
- Reducing administrative overhead by automating and standardizing prior auth workflows across all provider systems.
- Significant reduction in duplicate costs needed for patchwork solutions to the same problem.
- Managing one solution for all providers, ensures full and trusted compliance with the current, and upcoming CMS mandates.