The CMS Suite includes the ePA API which must be populated with:

- The payer’s list of covered items and services - Smile’s solution confirms a whether PriorAuth is required or not, in real-time at the point of care.

- Identification of documentation requirements for PriorAuth approval - Smile can automatically generate a request-specific questionnaire that can pre-populate responses directly from EHRs.

- Support a PriorAuth request and response - Smile’s workflow allows providers to submit requests and receive real-time responses, including approval, denial and reason, or requests for additional information.

The automated Payer to Payer workflow enables care continuity, by making claim, encounter, and prior authorization data from one payer available to another. Payers are required to share patient data with a date of service within five years of the request. Concurrent payers are required to exchange data quarterly. Payers need to offer members the ability to opt-into this data exchange.

Smile’s CMS Suite not only allows payers to meet these requirements, but also safeguards high-volume data exchange through patient matching, consent and security features.

Originally established in the CMS-9115-F Rule, this FHIR-based service allows patients (members in a payer’s network) to easily access their clinical, claims, and encounter data through third-party applications of their choice. The new CMS-0057-F Rule now requires payers to include information about prior authorizations to their members.  

Smile’s out-of-the box solution is easy-to-implement. Its CMS report and audit capabilities allow payers to submit patient or member usage metrics annually in accordance with the mandate requirements.

This API allows the patient data—including claims, clinical and prior authorization information—to be shared with relevant in-network providers. Payers must offer members an opt-out feature, enabling sovereignty of having their data available to other providers.

Smile’s solution accounts for identification, proper authorization and consent keeping data from payers, providers and members/patients secure and compliant. 

As part of the CMS-9115-F Rule, payers are required to make provider directory information publicly available via a FHIR-based API. Payers are required to offer transparency and support members in their search for care and treatment. This API also enables clinicians to find other providers for care coordination.

Smile’s quick and easy-to-integrate API allows payers to make this information available at their members’ fingertips.