Existing Wording: Currently, under HIPAA, providers and payers are required to use the 5010 version of the ASC X12 278 request transaction to request prior authorization and the 278 response to respond to that request. (See further details on relevant HIPAA requirements here.) While the X12 275, for additional documentation, is not currently required it is considered reasonable and appropriate to use this X12 transaction to support the exchange of the additional information that is required for prior authorization.

However, adoption of X12 by EHR implementers has been low.

Comment:

Since this work is being done on behalf of highly influential payors, consider seeing if a native FHIR-based approach can be accepted as alternate paths for prior auth. May not be achievable in timeframe, but what could be achievable is defining how things could work (and the benefits therein) if that could be made a reality.

Summary:

Explore native FHIR-based solutions to business problem.