SMILE PRIOR AUTHORIZATION

Up to 40% of inquiries do not even require Prior Authorization in the US. Automating Prior Authorization requests reduces the heavy burden on Payer intake teams, saving valuable time for both physicians and patients. For cases that do require approval, the Smile Prior Authorization (PA) solution meets CMS-0057-F compliance guidelines, and goes beyond by automating the process for in-network and out-of-network providers.

Smile Prior Authorization (PA) is a component of the CMS Suite and is aligned with the PA Payers’ Pledge of 2025. 

The solution is built on a fully computable, unified FHIR® and CQL foundation, capable of ingesting evidence-based narrative medical guidelines and policies, transforming them into computable policies published to the Payers’ content library. When a PA request is submitted by a provider, the Smile PA’s automated rules engine automates the adjudication based on the published policy, and sources information from the EHRs, eliminating the need for the Providers to manually supply the needed clinical information to support the prior authorization request.

With Smile PA, Payers can activate real-time prior authorizations, and reduce burden on their own adjudication teams, as well as the Providers, and operational costs. The rules and knowledge (content) engine that enables automated prior authorization, can further be used for digital HEDIS® quality submissions, and other use-cases like care gaps, risk and population health management, without re-creating workflows.