63.0.1Prior Authorization Solution

The Prior Authorization Solution enables electronic prior authorization workflows for both providers and payers, streamlining the submission, review, and management of requests.

With this solution, stakeholders can:

• Electronically determine if prior authorization is required
• Obtain payer coverage requirements
• Automate request documentation
• Submit and manage prior authorization requests
• Receive real-time responses

63.0.2Regulatory Context

The CMS Interoperability and Prior Authorization Final Rule CMS-0057-F mandates that payers enable electronic prior authorization (ePA) capabilities. This ensures that:

• Providers can submit requests efficiently and receive timely responses
• Payers process requests in a standardized, compliant manner
• Patient care is improved through faster authorization decisions

This aligns with broader goals of improving transparency, reducing administrative burden, and promoting interoperability across healthcare systems.