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  1. FHIR Specification Feedback
  2. FHIR-41619

Appeals should be in scope

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    • Icon: Change Request Change Request
    • Resolution: Considered for Future Use
    • Icon: Medium Medium
    • US Da Vinci PAS (FHIR)
    • current
    • Financial Mgmt
    • Formal Specification
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      We agree that electronic appeals should be considered for future use. We will be collecting metrics on the use of the Burden Reduction guides and we would like to have the metrics on denials and appeals so that we can judge how prevalent this issue might be.

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      We agree that electronic appeals should be considered for future use. We will be collecting metrics on the use of the Burden Reduction guides and we would like to have the metrics on denials and appeals so that we can judge how prevalent this issue might be.

      Appeals are currently out of scope for the Burden Reduction guides. However it would only strengthen the guides to have an automated appeals capability included.

      Given the current status quo, not to mention the increasing dependence on AI generated algorithms, we are concerned that payers may issue initial denials and defer the substantive work necessary for justifying a prior-authorization request to the very manual appeals process. This would derail all the great efforts that are being done here at Da Vinci.

      Not to mention, NCPDP ePA includes ability to do appeals. Given that drug ePA has this capability medical services PA should as well.

      Reading the tea leaves, there could be a future emphasis on the need to streamline the appeals process. For example, the CMS NPRM includes appeals in the metrics reporting requirement. It would therefore be in the industry's best interest to begin working on including this pretty critical piece of the puzzle to the overall prior auth workflow.

            Unassigned Unassigned
            celine_lefebvre Celine Lefebvre
            Celine Lefebvre
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