This guest article is written by Tyler Wince, Vice President of Product & Technology for Specialty Solutions at DrFirst. This article continues the Healthcare Regulatory Talk series. Prior authorization is a process capable of frustrating providers, payers, and patients equally.
Although sending and receiving electronic prior authorizations (ePAs) represent two sides of the same workflow, only one of those sides has been moving toward a modern standard—until now. A new proposed rule could soon address the flawed half of the system, offering workflow enhancements alongside new technological hurdles.
Last year, the Office of the National Coordinator for Health IT (ONC) issued a final rule mandating that electronic health record (EHR) vendors transmit prior authorization (PA) data via HL7 Da Vinci standards. The Centers for Medicare & Medicaid Services (CMS) has now proposed a rule that would require payers to adopt the same standard.
Under CMS-0062-P, both parties would be subject to identical mandates, replacing a partially manual process with a fully electronic, end-to-end workflow. It completes the efforts begun by the Health Data, Technology, and Interoperability (HTI-4) final rule by replacing a 30-year-old standard.
For the first time since 2006, the industry is moving away from the rigid X12 278 standard for medical ePA and replacing it with a modern, FHIR-first stack built on Da Vinci. CMS calls this shift a sea change in HIPAA Administrative Simplification. The key point is that aligning these rules guarantees that when an EHR sends a Da Vinci-based request, the payer receiving it must process it using the identical standard.
HTI-2 2024 mandates that EHRs implement the Da Vinci CRD, DTR, and PAS guides for electronic prior authorization. Meanwhile, CMS-0057-P would require impacted payers—including Medicare Advantage, Medicaid/CHIP, and Qualified Health Plan (QHP) issuers—to support those same Da Vinci implementation guides for medically billed prior authorizations by October 2026.
What Is Da Vinci? The HL24 Da Vinci Project is a collaborative multi-stakeholder accelerator that creates FHIR-based Implementation Guides to standardize data exchange between healthcare providers and payers.
