From Mandates to Momentum— a Payer Focused Video Series

Look for:

● A vision that extends beyond regulatory compliance.
● Technical evidence that they’re not just standing up APIs to ‘check-the-box’, and have demonstrable solutions that improve and streamline workflows.
● Plans (and technology) to evolve into new use cases, such as risk adjustment, and care-gap closure that would enhance member and provider satisfaction.

Don’t just ask if they “support FHIR.” Dig deeper:

● Are they based on a FHIR-native architecture?
● Do they actively participate in HL7 Technical Working Groups or help shape industry guidance?
● Do they have experience and expertise with Da Vinci Implementation Guides (IGs), and innovating with CQL?
● How do they leverage AI in their tooling? Do they use a deterministic evidence-based approach, or a probability-based approach?

● Do they offer technical and support services for provider education and onboarding support?
● Can they handle workflows like CDA ingestion and clinical data reconciliation?
● Are their systems battle-tested at scale in real-world implementations?

Look for:

● A data strategy that goes beyond API enablement and into data normalization, enrichment, and deduplication—essential for powering downstream use cases.
● Tools and automation that detect and correct data issues in real-time.
● An architecture that supports comprehensive, longitudinal records and analytics-ready data.

Can the vendor help you activate your data for:

● Risk adjustment and quality programs?
● Real-time prior authorization and care coordination?
● Utilization management or member engagement initiatives?

Is the vendor:

● Leveraging clinical guidelines and industry best practices?
● Able to prove consistent and accurate PA adjudications?
● Able to use an AI approach that resolves systemic biases, and is transparent and auditable?

● Allocate time for technical, business, and clinical teams to review the relevant Da Vinci IGs.

● Ensure teams understand the business problem each IG solves, along with the workflows it enables.

● Provide training on FHIR fundamentals if teams aren’t already proficient.

● Map your current prior authorization process end-to-end, including all provider touch-points, manual step and downstream systems involved.

● Review your current technology stack.

● Assess your privacy and security protocols in light of external-facing APIs and new data exchange requirements.

● Use the January 1, 2027 CMS deadline as your work-back date

● Align internal milestones, testing, and change management efforts to the timeline.

● View your vendors as partners. Share assessment findings and collaborate on how their solutions can help you meet compliance requirements.

● Assess vendor capabilities with detailed, specific questions:

● Is the vendor FHIR-first (FHIR-native), or do they rely on transformation layers?
● Which versions of CRD, DTR, and PAS IGs does the vendor support today?
● What is the vendor’s roadmap for adopting new versions or new IGs?
● Can the vendor demo a working implementation of FHIR and Da Vinci IGs?
● What professional services does the vendor offer for IG implementation and integration?

● Smile maintains the HL7 FHIR standard and our platform is the world’s most proven implementation.

● Smile is actively shaping industry standards by leading 31+ HL7 FHIR Working Groups.

● Smile’s CQL engine has been live in production for over 8 years, well before most vendors began investing in CQL for FHIR-based HEDIS measures.

● Key player in NCQA’s DQIC—Digital Quality Implementers Community—a key initiative validating vendor solutions against digital HEDIS measures.

● Fully compliant with CMS Prior Authorization (0057-F) requirements.

● Proven real-time prior authorization adjudication using codified medical policy, FHIR and CQL.

● Meets transparency expectations outlined in the Prior Authorization Payer Pledge.

● First and only vendor validated by NCQA under their new digital measure validation framework.

● Enterprise-scale processing, benchmarked at 5 billion data points (for 5 million members) in under 12.5 hours.