Medicare only pays for items and services when the provider’s medical record documentation indicates that all coverage and coding requirements were met. The Medicare documentation requirements appear in various locations and on separate websites causing burden to providers who must navigate the various websites to find coverage requirements, including documentation and prior authorization requirements.
What is Medicare doing to streamline access to requirements?
CMS is collaborating with ongoing industry efforts to streamline workflow access to coverage requirements, starting with developing a prototype Medicare Fee for Service (FFS) Documentation Requirement Lookup Service. The prototype will be made accessible to pilot participants and will be populated with 1) a list of items/services for which prior authorization is required, and 2) the documentation requirements for Oxygen and Continuous Positive Airway Pressure (CPAP) devices.
Please join us on June 25, 2020 from 2:00-3:00pm for a Special Open Door Forum (SODF) to introduce this new initiative and allow interested parties to provide feedback to CMS.
For more information and details on how to participate, check out the SODF Announcement (PDF) and SODF Slide Presentation (PDF).
We welcome your feedback! If you have any questions or comments, or are interested in participating in a future feasibility survey, please email us at MedicareDRLS@cms.hhs.gov.
- Reduce provider burden
- Reduce improper payments and appeals
- Improve "provider to payer" information exchange
How will this benefit providers?
Providers will be able to discover Medicare FFS prior authorization and documentation requirements:
- At the time of service
- Within their electronic health record (EHR) or integrated practice management system
For example, providers will be able to answer questions such as:
- Is prior authorization required by Medicare FFS for the item or service for which I’m about to refer my patient?
- Does Medicare FFS have documentation requirements for the item I’m about to order for my patient?
*API - Application programming interface
**FHIR - Fast Healthcare Interoperability Resources
CMS is participating in two workgroups to promote development of standards that will support the Medicare FFS Documentation Requirement Lookup Service. One workgroup is a private sector initiative hosted by Health Level Seven International (HL7), the Da Vinci project. The second workgroup, convened by The Office of the National Coordinator for Health Information Technology (ONC), is the Payer + Provider (P2) Fast Healthcare Interoperability Resource (FHIR) Taskforce.
By working with HL7, ONC, other payers, providers, and EHR vendors, CMS is helping define the requirements and architect the standards-based solutions. In parallel, CMS is preparing to support pilots testing the information exchanges for Medicare FFS programs and possibly coordinate pilots with volunteer participants to verify and test the new FHIR based solutions.
How can other health plans get involved?
CMS currently requires Medicare Advantage (MA) organizations to communicate their MA coverage and documentation guidelines to providers and, as appropriate, to enrollees. MA plans usually communicate these guidelines on separate websites causing burden to providers who must navigate various websites to find coverage and prior authorization rules.
We encourage all payers, including but not limited to Medicare Advantage organizations, Medicaid FFS, Medicaid managed care plans, Children’s Health Insurance Program (CHIP) and qualified health plan (QHP) issuers offering plans through an Federally-facilitated Exchange (FFE) (“issuers of QHPs in an FFE”) to follow CMS’s example and align with the Da Vinci project to: (1) develop a similar lookup service; (2) populate it with their list of items/services for which prior authorization is required; and (3) populate it with the documentation rules for at least Oxygen and CPAP. By taking this step, health plans can join CMS in helping to build an ecosystem that will allow providers to connect their EHRs or integrated practice management systems and establish efficient work flows with up-to-date information on: 1) which items and services require prior authorization and 2) what the documentation requirements are for various items and services under that patient’s current plan enrollment.
For IT developers who are interested, the first release of the Coverage Requirements Discovery (CRD) Reference Implementation (RI) Version 0.9 can be found on GitHub: https://github.com/HL7-DaVinci/CRD/releases/tag/v0.9
CRD provides an automated way for EHR systems to contact payer systems in order to determine requirements for prior authorization, specific documentation, prior treatments, appropriate use criteria and potentially gaps in care. The reference implementation is an open source software package created by MITRE that payers and EHR vendors can use, or test with, to build their own systems that work with the CRD standard.
HL7 Initiatives - Da Vinci
Da Vinci is a self-funded industry project hosted under the umbrella of HL7. The goal of the Da Vinci team is to develop FHIR Implementation Guides, and sample code to support the rapid development and deployment of interoperable services to enhance providers-payers exchanges and to reduce provider burden focused on value-based care requirements.
Two of the targeted Da Vinci use cases in 2018 are Coverage Requirements Discovery and Documentation Templates and Rules. CMS will incorporate the results of these use cases into the Medicare FFS Documentation Requirement Lookup Service.
Da Vinci will field test the use cases to validate the readiness of the services. The implementation guides, and sample code will be publicly available without additional cost. Select implementation guides will be brought through HL7's standards development process to be balloted as standards.
For more details or to get involved visit the HL7 Da Vinci project website.
ONC P2 FHIR Task Force
ONC is convening a group of highly-motivated payers, health information technology and healthcare organizations to collaborate on a focused effort to accelerate development of FHIR on a national scale and reduce variability in industry implementations.
This group, called P2 FHIR Task Force, will help CMS identify and solve infrastructure barriers that could prevent providers’ wide scale use of the Medicare FFS Documentation Requirement Lookup Service.
For more details visit the ONC P2 FHIR Task Force website.