Surescripts, Cohere expand prior‑auth automation

Surescripts and Cohere Health are both moving deeper into electronic prior authorization as CMS presses health plans and technology vendors toward standardized, API-based workflows. The timing matters because CMS’s interoperability and prior authorization rule already set compliance dates in 2027 for Medicare Advantage, Medicaid, CHIP and federally facilitated exchange plans. The practical effect is that prior authorization is starting to move out of phone calls, fax queues and payer portals and into software interfaces that EHRs and other clinical systems can query directly. ### What did Surescripts actually announce? Surescripts said on May 20 that it is expanding prior-authorization automation aimed at prescription approvals. The company said the effort is designed to cut delays in medication access by improving how authorization requests and related data move between prescribers, pharmacies, pharmacy benefit managers and payers. (hitconsultant.net) Hit Consultant reported that the expansion is tied to the broader push to reduce administrative friction in the prescription process. That matters because medication prior authorization has often depended on staff checking payer rules, gathering documents and following up manually when status updates are not visible inside the prescribing workflow. (hitconsultant.net) ### What is Cohere Health doing differently? Cohere Health said on May 20 that it supports CMS’s Health Tech Ecosystem initiative and the Electronic Prior Authorization Acceleration initiative. The company said it is aligning its work with health plans, providers and technology networks to make electronic prior authorization work “end-to-end” and on time for patients. (hitconsultant.net) Cohere said its technology team serves on the HL7 Da Vinci Project Steering Committee, which develops implementation guides for FHIR-based prior-authorization APIs. The company framed that work as part of closing technical gaps between payer systems and provider workflows. ### What is CMS trying to change before 2027? CMS said on May 13 that it launched the Electronic Prior Authorization Acceleration initiative to address key challenges ahead of 2027 requirements. (prnewswire.com) The agency said the effort sits within its Health Tech Ecosystem program and is meant to accelerate adoption of electronic prior authorization before the rule’s compliance dates arrive. (coherehealth.com) The CMS-0057-F final rule, released in January 2024, requires affected payers to improve electronic data exchange and implement prior-authorization APIs. The Federal Register notice says compliance dates for the Prior Authorization API policy land in 2027, including by January 1, 2027 for Medicare Advantage organizations and state Medicaid and CHIP fee-for-service programs, with corresponding 2027 timing for managed care and exchange products. (cms.gov) ### Why does FHIR matter in this story? FHIR is the interoperability standard behind the new prior-authorization interfaces that vendors and CMS are discussing. In practice, that means a provider-facing system can request coverage requirements, submit supporting information and retrieve authorization status through standardized APIs instead of relying only on phone calls, payer web portals or faxed forms. (cms.gov) CMS’s initiative is also drawing in early adopters to test those connections before the deadline. CMS said the acceleration effort is intended to solve operational problems ahead of the 2027 requirements, while outside reporting has described pilots spanning Medicare Advantage, Medicaid, CHIP and exchange plans using FHIR-based authorization interfaces. (cms.gov) ### What changes for EHRs and provider workflows? EHR vendors and provider organizations have a more realistic path to showing prior-authorization status inside clinical and administrative workflows if payers expose the required APIs. That means staff could see whether an authorization is pending, approved or missing information without checking multiple payer systems one by one — an inference supported by CMS’s API framework and the vendor announcements around workflow integration. (cms.gov) CMS said the point of the rule is to improve data exchange and reduce burden on patients, providers and payers. The next hard milestone is January 1, 2027, when major parts of the prior-authorization API requirements come due for Medicare Advantage and state Medicaid and CHIP fee-for-service programs, with related 2027 deadlines for managed care and exchange plans. (cms.gov) (hitconsultant.net)