CodeX Pilot Seeks to Simplify Prior Authorizations in Oncology

Aug. 31, 2022
Led by Evernorth and Varian, FHIR Accelerator pilot will test HL7’s mCODE-enabled prior authorization workflow in a real-world setting and eventually expand it to additional areas of oncology

Evernorth, the health services business of Cigna Corp., and Varian, a Siemens Healthineers company, will lead a radiation oncology-focused pilot project with the HL7 FHIR Accelerator CodeX to automate and expedite prior authorization processes between payers and providers.

The initial core focus for CodeX projects was integrating a standard language for cancer data called mCODE (minimal Common Oncology Data Elements) to support better, safer, faster cancer care, with lower burden and cost. CodeX recently announced efforts to leverage the CodeX/mCODE accelerator’s experience within two new domains: Genomics and Cardiovascular. 

Advances in the digitization of healthcare data, clinical workflows and real-time data exchange between providers and payers have created opportunities to make the prior authorization process easier and faster for all stakeholders. The CodeX pilot will build on this opportunity to improve care for people with cancer who need radiation treatment. 

“We joined CodeX to help drive better communication across the health care ecosystem and continue to optimize prior authorization to meet the needs of providers, patients and payers,” said Eric Gratias, M.D., an oncologist and chief medical officer for eviCore, an Evernorth company that manages medical benefits, in a statement. “Advancing health data interoperability in oncology is a community effort, and together, we have the opportunity to improve cancer care delivery and outcomes.”

Phase one of the radiation oncology-focused pilot concentrates on breast and prostate cancer and will build and test the exchange of prior authorization information between payer and provider systems using electronic health record test patients. Once validated, phase two will test HL7’s mCODE-enabled prior authorization workflow in a real-world setting and eventually expand it to additional areas of oncology.

“As a cancer care company, one of our main focuses is on finding ways to accelerate the path from diagnosis to treatment,” said Ashley Smith, vice president, oncology information systems at Varian, in a statement. “That’s why we’re so enthusiastic about participating in this project—because patients stand to benefit in the future.”

Pilot results will inform how providers and payers can apply mCODE-enabled processes to their prior authorization workflows. Providers and payers will benefit from more efficient workflows and less administrative burdens, and patients will experience more timely access to care and improved treatment outcomes.

Clinicians, payers, prior authorization vendors and radiation oncology-specific EHR vendors can join the pilot project to help shape the standard for how prior authorization is implemented before prospective regulatory requirements take effect.

CodeX members are leading health organizations across the care continuum. The following members are working with Evernorth and Varian on the prior authorization in oncology use case: American Society for Radiation Oncology (ASTRO), the Oncology Nursing Society (ONS), MCG Health, Mettle Solutions, Oncora Medical, Navigate Oncology and Telligen. Select practices in The U.S. Oncology Network will be among the first pilot sites.