Semantic Interoperability Solution for Electronic Prior Authorization and CMS Compliance
End-to-end FHIR® enabled semantic interoperability solution for orchestrating real-time prior authorizations between payers and providers.
The problem
Today's prior authorization workflows are hindered by administrative friction and fragmented systems that isolate data within silos. This reliance on non-standard, manual duplicative data entry creates substantial operational overhead for payers and providers, escalates administrative spend, and delays the delivery of care.
To reduce this administrative burden and improve health information exchange across the industry, CMS finalized the CMS-0057 rule, mandating standardized interoperability to streamline approval processes and put patients at the center of their own care.
The ZeOmega approach
HealthUnity Smart Authorization Gateway is an end-to-end FHIR® enabled workflow for submitting electronic prior authorization (ePA) requests directly from the providers' EMRs to payers and receiving an immediate decision back, saving time, lowering costs, and reducing delays in patient care.
The Smart Authorization Gateway comprehensively includes EMR integration, payer/provider workflows, medical policy integration and adjudication, administrative rules, and auto approval rules.
From the physician order to the payer decision.
Authorization Creation
- Creates auth shell from physician order (encounter, provider, request details)
- Identifies the payer
- Offers real-time benefits and eligibility check
- Provides real-time check for: “Is a prior auth required?”
Payer Requirements
- Loads corresponding medical review
- Loads administrative questionnaire
- Can load additional organizational criteria
- Includes FHIR Connectors for InterQual and MCG guidelines
Auto-Adjudication
- Supports extraction of clinical documentation from EMR
- Matches EMR data with clinical indications
- Works with MG Assist to extract data from clinical documentation
- Evaluates medical necessity and shares the review with the payer
Payer Decisioning
- Performs real-time prior auth submission
- Works with configurable auto-approval rules
- Verifies if medical necessity criteria are met
- Verifies if administrative policy is met
- Sends decision notification to provider
A digital bridge between payer and provider.
HealthUnity Smart Auth Gateway acts as a unified digital bridge between health plans and providers, natively embedding automated utilization management (UM) protocols directly into point-of-care workflows.
- CRD
Coverage Requirements Discovery
Evaluates patient eligibility within the provider's EMR to determine authorization requirements in real time, eliminating manual policy lookups and initial administrative friction.
- DTR
Documentation Templates and Rules
Allows providers to access health plan requirements directly from their existing workflow. These requirements are surfaced in the form of interactive clinical guidelines, including commercial guidelines (InterQual and MCG), CMS guidelines, as well as plan-specific policies. Smart Auth also integrates with AI capabilities such as MG Assist to pre-populate responses using the included clinical documentation.
- PAS
Prior Authorization Support
Bundles supporting clinical evidence and transmits the request directly to the payer, handling complex technical conversions to enable real-time auto-approvals or prompt routing. PAS also provides automated, real-time notifications to providers on status changes, determination decisions, or additional information requests.
Greater transparency. Faster time to therapy.
See a prior auth go from EHR to decision.
We'll walk through a request from the physician order to the payer's response.