What You Should Know
- The Office of the National Coordinator for Health IT (ONC) and the Centers for Medicare & Medicaid Services (CMS) jointly announced a nationwide industry testing initiative to validate end-to-end electronic prior authorization (ePA) workflows in production-like environments ahead of 2027 federal requirements.
- The program convenes health plans, hospitals, clinical providers, electronic health record (EHR) developers, and clearinghouse intermediaries to execute collaborative, 10-to-12-week testing sprints designed to uncover technical and operational gaps prior to scaled deployment.
- Testing events center on high-volume and high-priority clinical services utilizing the HL7® FHIR® Da Vinci implementation guides for Coverage Requirements Discovery (CRD), Documentation Templates and Rules (DTR), and Prior Authorization Support (PAS).
Operationalizing the HL7 FHIR Da Vinci Stack
To execute end-to-end testing across high-volume and high-priority clinical services, ONC and CMS have anchored the initiative around the HL7 FHIR Da Vinci Burden Reduction implementation guides, utilizing dedicated testing infrastructure operated by federal and private-sector partners.
The technical workflow evaluates three sequential interoperability specifications across simulated clinical encounters. First, Coverage Requirements Discovery (CRD) enables a provider’s EHR to query a payer’s system in real time at the point of order entry to determine whether a proposed service or procedure requires prior authorization. Second, Documentation Templates and Rules (DTR) pulls payer-specific clinical documentation requirements directly into the clinical workflow, allowing automated extraction of structured data from the patient’s chart without manual data entry. Third, Prior Authorization Support (PAS) packages the clinical evidence into a standardized FHIR payload and transmits it electronically to the health plan for automated adjudication and immediate status tracking.
To manage recruitment, participant matching, and technical execution, ONC and CMS engaged the MITRE-led Health Federally Funded Research and Development Center alongside conformity assessment organization Drummond Group. Drummond Group will host the testing sprints on FHIRplace, a virtual interoperability testing environment that allows EHR vendors, payers, and intermediaries to simulate real-world transactional traffic across connected endpoints.
Federal Policy Alignment: Preparing for the 2027 Regulatory Cliff
Executive leadership at ONC emphasized that publishing technical standards is insufficient unless payers and health IT developers validate how those standards perform under live clinical conditions. Tom Keane, M.D., National Coordinator for Health IT, stated that while federal regulations and industry standards have established essential groundwork for electronic prior authorization, advancing the next phase of implementation testing with CMS is vital to accelerating industry progress in the near term.
The November 12 announcement follows a broader series of federal actions throughout 2026 aimed at enforcing prior authorization transparency and reducing administrative burden. Under CMS regulations, impacted payers—including Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, and Qualified Health Plan issuers on the federally facilitated exchanges—must deploy standardized Prior Authorization APIs by January 1, 2027, alongside stricter turnaround times of 72 hours for expedited requests and seven calendar days for standard decisions. Furthermore, CMS finalized an electronic prior authorization quality measure that becomes an optional bonus metric for eligible clinicians and hospitals in calendar year 2027 before becoming mandatory in 2028, creating direct financial incentives for providers to adopt FHIR-based authorization workflows.
“Federal regulations and industry standards have laid important groundwork for ePA, but our work is not done,” said Tom Keane, M.D., National Coordinator for Health IT. “With our colleagues at CMS, we are bringing partners together to advance the next phase of implementation testing to accelerate ePA progress in the near term.”
