Health care clinicians face many challenges in understanding complex coverage requirements, including documentation and prior authorization requirements, for multiple payers when ordering or providing different items and services. Currently, 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. This consumes staff time unnecessarily and can lead to instances where documentation requirements are not fully understood or gathered. Significant efficiencies in the process for discovering coverage requirements at the time of service could be gained through automation. A critical gap in this area is the lack of interoperability and standardization between electronic health record (EHR) systems and payers to allow the exchange of information at the time of service and within the clinical workflow. Without a standard method for the payer to communicate requirements to the provider through the EHR, this will remain largely a manual process.

To address this issue, the CMS Center for Program Integrity (CPI) 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 (DRLS). One industry workgroup is a private sector initiative hosted by the Health Level Seven International (HL7) Da Vinci project. Two of the initial targeted Da Vinci use cases are Coverage Requirements Discovery (CRD) and Documentation Templates and Rules (DTR). CMS will incorporate the results of these two use cases into the Medicare FFS DRLS and pilot-test DRLS rule sets for two durable medical equipment (DME) items, based on the CRD and DTR standards. This session will describe how the DRLS will operate in a clinical setting, and provide insights into how the DRLS applies the two standards, CRD and DTR. It will also explain how these standards are built upon existing standards such as CDS Hooks and Fast Healthcare Interoperability Resources (FHIR) to allow for rapid adoption by other health IT vendors.

Describe the new knowledge and additional skills the participant will gain after attending your presentation.: The participants will:
1) Understand how providers can find DME documentation requirements using automated processes
2) Gain knowledge of data standards for reducing prior authorization workflow burdens
3) Learn how to use data standards to provide a better documentation experience for providers


Melanie Combs-Dyer (Presenter)
Centers for Medicare and Medicaid Services

Presentation Materials: