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The healthcare industry continues to make significant strides in improving the prior authorization process and reducing administrative burden through improved interoperability. During the HL7 FHIR Connectathon 38 last month, 1upHealth demonstrated successful use of the recommended APIs laid out in the CMS-0057-F rule, marking an important milestone towards true digital prior authorization that will ultimately lead to improved patient outcomes and reduced provider burden.
Breaking New Ground in Electronic Prior Authorization
Our team participated in the Burden Reduction Track, where we partnered with Itiliti Health to successfully demonstrate the Coverage Requirements Discovery (CRD) flow across multiple healthcare systems. The demonstration showcased seamless communication between EHR systems, QHINs, policy managers, and payers, highlighting the potential for a significant reduction in administrative overhead for healthcare providers and payers when these capabilities are expected to be enabled broadly on January 1, 2027.
These collaborations led to successful demonstrations of both “Auth Required” and “No Auth Required” scenarios, all displayed in real time within an EHR. The system effectively communicated additional information along with clinical guidelines when appropriate, giving healthcare providers clear direction at the point of care. Imagine: Instead of a follow-up phone call from a clinic administrator the day after a scan is ordered, the physician receives guidance on how to best get you the care you need while you’re in the room with them.
Here are my 3 major lessons learned.
3 Lessons Learned
The implementation journey uncovered learnings that only emerge during practical application. Our team navigated various technical scenarios, including the use of CDS hooks, multiple coverage scenarios, and proper authorization messaging. Each challenge provided valuable feedback that will help shape future iterations not only of 1upHealth’s prior authorization solution, but also of the standards and implementation guides themselves.
1. The Value of Standards
Within two working days, we were able to successfully transact multiple prior authorizations between four distinct systems. This speed of integration would have been unthinkable in the past, where custom interfaces between systems could take weeks to develop and test. Building on shared specifications meant that each organization could focus on their core competencies while still ensuring seamless interoperability. This real-world demonstration proved that the industry’s investment in common frameworks is a key step to true healthcare interoperability.
2. The Importance of Early Testing
Even with carefully documented specifications, technical implementations can vary significantly across different vendors and organizations. Early testing helps identify these variations before they impact production environments. Our experience showed how small differences in the interpretation of standards requirements – from data formatting to API behavior – can create integration challenges. By testing early and often, organizations can address these discrepancies proactively rather than discovering them during real-world implementations. Details matter and often the right answer is just to put the work in.
3. Evolving Standards
Beyond just technical implementation differences, real-world usage reveals new scenarios and business requirements that weren’t considered in the original standards drafting. During the Connectathon, we encountered novel use cases around multiple coverage scenarios that weren’t explicitly addressed in current specifications and which led to unclear failure states. Future iterations of the standard could be updated with clearer guidelines for properly handling multiple coverage scenarios as well as clearer error messages for various failure states.
Looking Forward
One thing that has become even more clear after participating in the Connectathon is that a successful implementation of digital prior authorization, both for an individual customer and for the industry broadly, requires multiple technology partners to work more closely together than ever before. As we look to the future, our team is committed to working with various partners in the development of our Prior Authorization APIs and collectively refining the standards to ensure innovation and true healthcare interoperability.
The path forward is clear. Through continued industry collaboration and dedication to standards-based development, we can turn the promise of digital prior authorization into a reality, dramatically reducing administrative burden while helping patients receive faster access to appropriate care. The success 1upHealth and several other industry partners had at HL7 FHIR Connectathon 38 shows we’re not just envisioning this future – we’re building it.
