Use Case 3: Electronic Prior Authorization (ePA) Solution for Payers and Providers

Requirements:

The new CMS rule requires all Payers to implement electronic Prior Authorization capabilities using FHIR APIs starting on January 1st, 2026. The biggest challenge in implementing the prior auth requirements is to integrate the providers and the payers using the FHIR APIs. This is further complicated for Payers who must meet their current PA requirements but ensure that the solution will continue to support evolving electronic Prior Authorization regulations .

Challenges:

Current Prior Authorization implementations vary from manual request and response management to semi-automated processes. The existing processes are extremely burdensome and take long wait times for patients and currently there are no standards based electronic Prior Auth APIs in-place.

Solution:

Leveraging the DaVinci Implementation specifications for Coverage Requirements Discovery (CRD), Documentation Template and Requirements (DTR) and Prior Authorization Requests/Responses (PA), iX DataBridge implements the necessary capabilities that can be used by Payers to integrate with their providers using different EHR systems and at the same time integrate with the Payer backend systems. iX DataBridge uses various translations to integrate the Payer systems successfully with the ePA applications.

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