ePA in Action: Webinar Recap and Q&A 

1upHealth recently hosted a live webinar focused on electronic Prior Authorization entitled “ePA in Action: Live Demo + Roadmap to CMS-0057 Compliance.”

During the session, our Chief Product & Technology Officer Mohammad Jouni and members of the Product and Account teams shared how our electronic Prior Authorization (ePA) solution is taking the complexity out of the CMS Interoperability and Prior Authorization final rule (CMS-0057) and making it easier for health plans to:

• Cut administrative costs and speed up care with automated prior authorization.
• Reduce provider friction with in-workflow PA submissions.
• Stay ahead of CMS-0057 requirements before the January 2027 deadline.

ePA Webinar Questions & Answers

Webinar attendees asked our compliance and interoperability experts a lot of really great questions throughout the live webinar. The questions were so great, we figured we’d feature them in a blog. Check them out below.

Q: Can we see some overall system-level architecture to understand how all the components are communicating with each other?

A: Reach out to 1upHealth for a detailed walkthrough. At a high-level:

• Multi-tenant API gateway for CRD/DTR/PAS
• Routing engine
• Kafka-based event stream for audit and metrics
• EHR connectivity via SMART on FHIR + OAuth2
• UM system connections using FHIR APIs

Q: Are you using a CQL-based approach for CRD Rule Management?

A: No, 1upHealth does not use a CQL-based approach for CRD Rule Management. Logic is evaluated against the spreadsheet rules or a simplified rule-matching engine. 

Q: How does the spreadsheet understand the rules and logic to be evaluated? Is the creation automated or manual?

A: The rules spreadsheet functions as a structured input for 1upHealth’s database that powers routing and decision support. The spreadsheet typically includes:

• CPT/HCPCS Codes
• PA Required or Not Required
• Routing Destinations (UM vendor or internal system)

The process is semi-manual:

• 1upHealth provides a template and extract guide, and may assist with format standardization.
• Customers complete the spreadsheet based on internal Utilization Management (UM) policies or delegation logic.
• Customers upload to an SFTP server. 

Reach out to 1upHealth for an example spreadsheet. 

Q: Is there a pharmacy module that would cover Medication Prior Authorizations?

A: At present, our focus is on Medical Prior Authorization, aligned with the CRD/DTR/PAS Implementation Guides (IGs). Medication PAs may eventually be supported through integration with Pharmacy Benefit Managers (PBMs) or future IGs, but are not currently in scope unless routed through a UM system that handles both.

Q: Do you support PAS subscriptions for async decisions?

A: Yes, the PAS endpoint supports FHIR Subscription mechanisms to notify systems when a determination is ready, particularly when the UM process cannot return an immediate response.

Q: How does the system behave if the data is not available in FHIR while generating the decision? Does it consider it as a failure or something else? Example: If we are evaluating gender data as part of a rule, but for some scenario gender info is not available.

This would be dependent on the UM vendors and other PA systems that are on the receiving end of the submission. 

Q: How will your system address states that have restrictive (i.e., shorter turnaround times) for Prior Authorizations? Some states have a 2-business day turnaround time. 

1upHealth’s system ensures that PAs are delivered to UMs and decisioning entities in a timely manner. From there, the UM or decisioning entity is responsible for adhering to shorter turnaround times on a state-by-state basis. 

Q: Do we write anything back to EHR for progress on Prior Authorizations? Any particular FHIR resources you use for it? Writing anything to EHR is a bit hard and not all EHRs allow/support it.

A: Generally, writing back to EHRs is limited, as many EHRs restrict this capability. When supported, 1upHealth may use:

• Communication or Task resources to post updates
• ClaimResponse resource for PAS decisions

In most cases, the EHR polls or subscribes to status via CRD or PAS, rather than having data written directly back.

Q: Will your ePA solution also issue denials? States often have laws that only a physician can issue a denial, not an algorithm. Please clarify. How will you work with providers that don’t have a FHIR-compatible EHR? Or worst-case scenario, still use paper? 

The platform can return a denial, but 1upHealth is not acting as the final decision-maker. Instead:

• Denial reasons come from the UM system or provider group.
• 1upHealth merely facilitates the transport and format.
• In states where only physicians may issue denials, this responsibility remains with the delegated decision-making entity, not the platform.

ePA Webinar Now Available to Watch On-Demand

It’s not too late. If you missed the webinar, you can now watch it on-demand to:

• Gain an understanding of CMS-0057 ePA requirements.
• Learn how 1upHealth is taking a flexible approach to ePA to ensure our customers achieve compliance, regardless of their utilization and policy management vendors.
• See a demo of our ePA solution in action.
• And much more… 

You can also check out our 1up Prior Authorization web page to learn more.