Much of the work being done with FHIR in the US is driven by regulation.
These regulations are ambitious and ongoing, leading to almost continuous development work by companies in the healthcare space.
The focus over the past year has been on the “Prior Authorization Final Rule.”
If you work for a US organization you’ll be intimately familiar with this. If you don’t, you might have been scratching your head for the past year wondering what people are talking about.
Here’s a brief run down of the ruling, but let’s start with a layman’s description of a couple of key terms.
- “payer”
Insurer / insurance company. - “prior authorization”
A request to an insurer to approve services and provide benefits.
There are 5 key areas in the rule, each requiring different data to be exposed via FHIR and each affecting different types of organizations. Most come into force in January 2027.
- Patient Access API
Expose prior authorization requests and decisions to patients. - Provider Access API
Payers to implement APIs to make Claims and Encounter data available to providers, as well as specified prior authorization information. Also enable bulk data access. - Payer-to-Payer Access API
Similar data to the Provider Access API. The aim here is to make it easier for patients to move between health insurance providers. - Provider Directory API
Various programs must make provider information easier to access. - Prior Authorization API
To be implemented by payers, this helps providers to determine if a prior authorization is required and to provide detail on approvals, denials, reasons for denial, and more.
The requirements are well documented, right down to the recommended and very detailed Implementation Guides that should be used for each API.
APIs and Implementation Guides.
Here are some additional links if you want to spend some time getting up to speed.
I vastly over simplify here, and I recommend anyone interested dig deeper into the links provided.
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