Provider Compliance Group Fast Healthcare Interoperability Resources (PCG-FHIR)

CMS is continuously looking for ways to improve efficiencies with the overall goal of serving beneficiaries better while safeguarding the Medicare Trust Fund. As part of these efforts, CMS is encouraging stakeholders to move towards smarter data request processing with the objective of achieving real-time, accurate and faster responses.

CMS’s Provider Compliance Group (PCG) is leveraging the Fast Healthcare Interoperability (FHIR) technology, a Health Level Seven or HL7 standard, for exchanging healthcare information electronically between different systems through its PCG-FHIR Server. Using the PCG-FHIR Server will allow for the processing of various healthcare transactions such as Prior Authorization (PA) requests and Additional Document Requests (ADR) responses with the following benefits:

Reducing Provider Burden

With PCG-FHIR, clinical and administrative data can be bundled as a single transaction and submitted as one request. With the ability to submit clinical and administrative attachments as one transaction, Review Contractors (RCs) are able to continue with their current processing method using a PDF attachment while transforming information into a single usable form through FHIR.

Faster Status and Responses from RCs

Using PCG-FHIR for prior authorization requests may allow for faster status and responses from RCs who are currently using the Electronic Submission of Medical Documentation (esMD) channel to deliver the X12 278 requests and attachments to providers.

Real-Time or Near Real-Time Responses

In the past, ADR letters were sent via U.S. Mail resulting in backlogs and delays in processing claims. The PCG­-FHIR Server enables RCs to send ADRs and Providers to submit ADR responses electronically in FHIR Format through esMD converting the responses into FHIR format or PDF format. This allows requests to be processed faster resulting in real-time or near real-time responses. As with PA requests, by utilizing esMD, no internal system changes are required for receiving ADR responses.

Join the PCG-FHIR Pilot

We invite RCs and Providers to participate in testing and piloting the PCG-FHIR technology for PA requests and ADR responses. If you are interested in testing and piloting the PCG-FHIR Server, please send an email to: pcg-fhir@mettles.com