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I talked to Nikki Henck, Senior Director of Utilization Management at Sagility , about the implementation and potential impact of this proposed requirement, which, if finalized, will be enacted in January 2026. The release of FHIR in the mid-2010 decade changed everything. These factors are incentives for adoption.
Up first: Using bulk FHIR. What is bulk FHIR? Like many aspects of HL7 ® Fast Healthcare Interoperability Resources (FHIR ® ), there has been a lot of hype about the potential of using bulk FHIR to get large amounts of data out of EHRs. That’s where bulk FHIR comes in.
The CMS proposed ruling requires impacted payers to build and maintain a FHIR API, starting January 1st, 2026, in effort to improve the cumbersome and costly prior authorization process. This will further endeavor to cement FHIR as the data standard to support future information exchange. Clay Ritchey, CEO at Verato.
In the State of California, there is a mandate for improved data sharing for smaller entities by Jan 2026, and they are even providing incentives to get it done. FHIR-based API usage by Payers (Government and Commercial) in the next few years will usher in enriched datasets to TEFCA networks.
More time to comply with API requirements The finalized rule requires that both payers and providers update or implement a variety of HL7® Fast Healthcare Interoperability Resources (FHIR®) APIs. In other words, Prior Authorization APIs will be compliant if they use FHIR and X12, or purely FHIR. X12 to FHIR) or small (e.g.
Small physician practices, rehabilitation hospitals, long-term acute care hospitals, acute psychiatric hospitals, small rural acute care hospitals, and nonprofit clinics will have until January 2026. Of note, the XCPD, XCA, and XDR profiles do not currently support FHIR natively.
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