PRIOR AUTHMONITOR

Follow the rules. Understand the workflow. Protect access to care.

Authority library

Rules and standards record

Each record preserves the issuing authority, jurisdiction, instrument or authority type, legal or operating status, version and application dates, affected audience, workflow mapping, source link, and interpretation boundary.

United States; specified Medicare Advantage, Medicaid, CHIP, and Federally-facilitated Exchange payer programs · U.S. federal final rule

CMS-0057-F

The rule requires impacted payers to improve prior authorization decision timeframes and denial reasons, publish aggregated prior authorization metrics, and implement FHIR-based Prior Authorization and other interoperability APIs. The prior authorization API provisions addressed by the final rule exclude drugs.

Final and effectiveCenters for Medicare & Medicaid Services

United States; proposals affect specified CMS-regulated payers and certain HIPAA covered entities · U.S. federal proposed rule

CMS-0062-P

The proposal would extend many electronic prior authorization, decision-time, transparency, API, and reporting policies to drugs and would adopt or update FHIR-based standards and implementation specifications for prior authorization transactions. The proposals are not final policy.

Proposed; public comment closed June 15, 2026Centers for Medicare & Medicaid Services, Department of Health and Human Services, and Office of the National Coordinator for Health Information Technology

United States realm · FHIR implementation guide

HL7 Da Vinci PAS v2.2.1

PAS defines a FHIR R4 mechanism for submitting prior authorization requests, responses, status, updates, and supporting context in a way designed to map to applicable X12 transactions. It is one part of the Da Vinci burden-reduction workflow.

Standard for Trial Use, active current published versionHL7 International Da Vinci Project

United States realm · FHIR and CDS Hooks implementation guide

HL7 Da Vinci CRD v2.2.1

CRD enables a provider workflow to query a payer for patient- and service-relevant coverage expectations such as whether prior authorization is required, documentation expectations, first-line treatments, or related instructions. It does not itself submit the authorization request.

Standard for Trial Use, active current published versionHL7 International Da Vinci Project

United States realm · FHIR, Questionnaire, and CQL implementation guide

HL7 Da Vinci DTR v2.2.0

DTR lets payers express documentation requirements computably and allows provider systems or SMART applications to retrieve existing clinical data, prompt for missing information, and create structured responses for downstream authorization or claims workflows.

Standard for Trial Use, active current published versionHL7 International Da Vinci Project

United States HIPAA covered-entity transactions · HIPAA-adopted administrative transaction implementation guide

X12 278 Version 5010

The 278 implementation guide defines request and response transactions for admission certification, referrals, service certification, extensions, appeals, reservations, and cancellations between providers, utilization-management organizations, and intermediaries.

Adopted transaction baseline; newer X12 versions exist but require separate adoptionASC X12

United States prescription and pharmacy transactions · federally adopted electronic prescribing transaction standard

NCPDP SCRIPT v2023011

SCRIPT is the core U.S. e-prescribing standard and includes transactions for electronic prior authorization and medication history. Version 2023011 adds required ePA transactions and other prescribing enhancements.

Final and federally adopted for future required useNational Council for Prescription Drug Programs

United States healthcare organizations performing utilization management · voluntary healthcare accreditation program

NCQA UM Accreditation

NCQA UM Accreditation evaluates organizations that make utilization decisions against a framework for objective, evidence-based, fair, and timely operations. Detailed standards cover clinical information, review processes, timeliness, appeals, and related controls.

Current accreditation program; detailed standards are licensedNational Committee for Quality Assurance

United States healthcare organizations performing utilization management · voluntary healthcare accreditation program

URAC Health UM Accreditation

URAC accredits health utilization-management organizations against standards intended to support effective, transparent, and efficient UM functions, including organizational accountability and consumer protections.

Current accreditation program; detailed standards require program materialsURAC

United States Medicare Advantage organizations · Medicare Advantage oversight data collection

CMS Part C UM Annual Data Submission

The collection requires Medicare Advantage organizations to submit information about internal coverage criteria used by the organization or delegated entities to process Part C prior authorizations, increasing oversight of policy and delegation practices.

Finalized; submissions begin in 2026Centers for Medicare & Medicaid Services

How to read the library

Binding requirements, official guidance, technical standards, implementation guides, program rules, and authority data are not interchangeable. Each page names the source class and states what it can and cannot establish about an organization or product.