50.0.1Prior Auth CRD (Coverage Requirement Discovery) Module Overview

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50.0.2Prior Auth CRD (Coverage Requirement Discovery) Introduction

The Coverage Requirements Discovery (CRD) module in Smile Digital Health facilitates interactions between the Electronic Medical Record (EMR) systems, referred to as the Client, and the payer systems to determine prior authorization requirements for specific healthcare services to be provided to a patient.

Built on the Fast Healthcare Interoperability Resources (FHIR®) standards, Prior Auth CRD aligns with the HL7 Da Vinci Coverage Requirements Discovery (CRD) implementation guidelines (IG). The Prior Auth CRD module supports FHIR® version R4 and enhances the prior authorization workflow with several key features:

• Prefetching Required Data Resources: The module can automatically fetch necessary data resources required for prior authorization.
• CQL Engine for Prior Authorization Determination: Utilizes Clinical Quality Language (CQL) to evaluate the authorization requirements.
• Provider Eligibility Checks: Ensures that the provider is eligible to request the prior authorization.

The module uses CDS Hooks to register as an endpoint service on the server and consists of several components:

1. Registration as a CDS Service: The module registers and becomes discoverable via the CDS Hooks Discovery Endpoint.
2. Support for CDS Hooks Requests: Specifically handles order-sign requests.
3. CQL Determination Engine: Processes the business logic for authorization.
4. Response Handling: Returns coverage eligibility information based on the authorization determination.

50.0.3Prior Auth CRD (Coverage Requirement Discovery) Module Overview

50.0.3.1CDS Service Discovery

The Prior Auth CRD module registers itself as a CDS Service. Accessing the endpoint at {{baseUrl}}/cds-services will return a list of endpoints for the available services. The Prior Auth CRD will be listed among the CDS Services on the discovery endpoint. This list includes:

• Endpoint URLs: The specific endpoints that can be accessed.
• Required Resources: The necessary data resources that must be submitted with the order. If these resources are not provided, the module will automatically prefetch them using the provided authentication.
• Configuration Options: Available configuration details are provided via the davinci-crd.configuration-options extension.

50.0.3.2Processing Hook Request

• The client sends a request containing the necessary fields for prior authorization.
• After determining the Patient in context, a request is submitted to the CQL Engine via the PlanDef/$apply operation.

50.0.3.3CQL Engine Processing

The CQL Engine evaluates the business logic and determines whether the requested service requires prior authorization. It then returns a response containing the authorization determination.

50.0.3.4Returning Response

The Prior Auth CRD module processes the response from the CQL Engine and returns it to the client, providing the necessary coverage eligibility information and prior authorization status.