What You Should Know
- Four major health systems—Ochsner Health, Froedtert ThedaCare Health, Denver Health, and Summit Health—have deployed real-time prior authorization checks directly inside their native Epic EHR workflows.
- The rollout utilizes the industry-standard Coverage Requirements Discovery (CRD) API, enabling clinical and financial clearance teams to determine instantly whether a commercial or government payer requires prior authorization at the point of order entry or appointment scheduling.
- Participating health plans live on the network include UnitedHealthcare, Aetna, and Network Health, with 16 additional health insurers currently undergoing active integration testing.
- The joint provider-payer deployment goes live more than five months ahead of the Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization final rule deadline of January 1, 2027, which mandates electronic prior authorization APIs across Medicare Advantage, Medicaid, and ACA marketplace plans.
- The automated CRD connection eliminates the need for manual payer portal lookups, phone calls, faxes, and internally maintained spreadsheet matrices that quickly become outdated.
Eliminating Front-End Prior Authorization Uncertainty
Determining whether an upcoming medical procedure, diagnostic scan, or specialty medication requires prior authorization has historically forced provider organizations to maintain static internal matrices, navigate fragmented payer portals, or make manual inquiry phone calls. This administrative ambiguity frequently leads to unnecessary scheduling holds for non-gated treatments or unexpected retrospective claim denials when requirements shift unnoticed.
Epic’s CRD API integration automates coverage discovery at the earliest clinical touchpoints:
- In-Workflow CRD Decision Support: Uses the HL7 FHIR Da Vinci Project Coverage Requirements Discovery (CRD) standard to automatically surface authorization requirement flags at the exact moment a clinician enters an order or schedules an appointment, eliminating duplicate manual data entry across external payer portals.
- Live Multi-Payer Ecosystem: Operating in live production environments with national and regional health plans—including UnitedHealthcare, Aetna, and Network Health—with an additional 16 payers actively undergoing end-to-end sandbox testing.
- Pre-Empting Federal Interoperability Mandates: Goes live more than five months ahead of the CMS Interoperability and Prior Authorization final rule deadline (mandating standardized API support across Medicare Advantage, Medicaid, and ACA marketplace plans by January 1, 2027).
- Administrative & Scheduling Acceleration: Instantly clears procedures that do not require prior authorization for booking, while automatically triggering electronic authorization assemblies for treatments requiring clinical review.
“At Ochsner Health, we’re excited to implement the Prior Authorization API, which transforms a traditionally manual, time-consuming process into a streamlined experience for our care teams. This will reduce administrative burden, improve efficiency, and minimize delays in patient care.”
— Melissa Woods, Assistant Vice President of Revenue Cycle and Financial Clearance, Ochsner Health
