{"entity":{"id":"idea-cost-real-time-pa-fhir","kind":"idea","name":"Answer prior authorisation requests in seconds from the medical record","aka":[],"tldr":"Most cancer drug approvals depend on a handful of facts already in the chart, such as the diagnosis, biomarker and line of therapy; sending those automatically in a standard format would return most decisions before the patient leaves the room.","summary":"CMS's 2024 Interoperability and Prior Authorization final rule requires payers to offer electronic prior authorisation through HL7 FHIR interfaces and to decide urgent requests within 72 hours and standard ones within seven days from 2026 and 2027. Oncology criteria are structured (diagnosis, stage, biomarker, prior lines), so the mCODE data standard can carry them. Payers publishing their oncology rules as computable criteria, and electronic records sending mCODE bundles, turns a fax-and-phone process into an automated one with human review only for exceptions.","asOf":"2026-09-10","links":[{"label":"CMS Interoperability and Prior Authorization final rule (CMS-0057-F, January 2024)","url":"https://www.cms.gov/priorities/key-initiatives/burden-reduction/interoperability/policies-and-regulations/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f"}],"tags":[],"related":[],"cancers":[],"sections":[],"technologies":[],"targets":[],"drugs":[],"companies":[],"institutions":["hl7"],"pathways":[],"terms":["mcode","nccn-compendium"],"trials":[],"people":[],"bottlenecks":["b-care-fragmentation","b-data-silos","b-workforce"],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"hypothesis":"Automated FHIR-based oncology prior authorisation will decide more than 70% of requests within one hour and cut practice administrative cost per request by more than half.","rationale":"The regulatory deadlines are set; the data standards exist; the remaining work is mapping each payer's criteria into computable rules.","test":"Payer and practice pilots reporting decision times, share auto-approved, appeal rates and staff hours before and after.","maturity":"being-tested-at-scale","actor":"data","cost":"medium","horizonYears":2},"route":"/ideas/idea-cost-real-time-pa-fhir/","neighbours":{"institution":[{"id":"hl7","kind":"institution","name":"HL7 International","route":"/institutions/hl7/"}],"term":[{"id":"mcode","kind":"term","name":"mCODE (minimal Common Oncology Data Elements)","route":"/terms/mcode/"},{"id":"nccn-compendium","kind":"term","name":"NCCN Compendium and drug compendia","route":"/terms/nccn-compendium/"}],"bottleneck":[{"id":"b-data-silos","kind":"bottleneck","name":"Data silos","route":"/bottlenecks/b-data-silos/"},{"id":"b-care-fragmentation","kind":"bottleneck","name":"Fragmented care and guideline gaps","route":"/bottlenecks/b-care-fragmentation/"},{"id":"b-workforce","kind":"bottleneck","name":"Not enough oncologists, nurses, pathologists, physicists","route":"/bottlenecks/b-workforce/"}]}}