Oncology Medication Prior Authorization at the HL7 Connectathon: Da Vinci CRD, DTR, and PAS

Oncology prior authorization is a workflow problem, not just a form problem. The order is often a regimen. The clinical context lives across several systems. And the payer needs enough structure to evaluate medical necessity without sending a clinician back to another portal.

The HL7 Connectathon on September 19–20 in Rockville, Maryland is the next place to compare that proposal against implementer experience.

We are working with HL7 CodeX continuing standards work on medication prior authorization for anti-cancer regimens. The base is Da Vinci’s Coverage Requirements Discovery (CRD), Documentation Templates and Rules (DTR), and Prior Authorization Support (PAS) implementation guides. In broad terms, CRD can surface coverage and documentation requirements during the ordering workflow; DTR can gather the required documentation; and PAS supports a structured prior-authorization submission and response. The published guides describe that relationship in detail: CRD and PAS.

Oncology makes the ordinary case more demanding. A decision may involve a multi-drug regimen, disease context, treatment intent, line of therapy, biomarkers, prior treatment, and documentation that lives across more than one clinical system. A single medication order does not always express the unit a payer needs to evaluate.

Our current work is a proposal for that gap, not a new published Da Vinci standard. It models the patient-specific ordered regimen as a FHIR RequestGroup, linked to an optional reusable PlanDefinition, and uses versioned DataRequirement entries to make the needed patient context explicit. The proposal can then use CRD to identify whether the available context is sufficient, DTR to collect what is missing, and PAS if an authorization request still needs to be submitted.

A structured request can make the record and the payer’s requirements easier to exchange. It does not determine the right treatment, establish medical necessity by itself, or replace clinical and payer review.

Consulting for CMS-0062

CMS-0062-P (proposed) would extend prior authorization to drugs and broaden this workflow. Our consulting services support teams working through that direction: Da Vinci CRD/DTR/PAS workflow design, regimen-level FHIR modeling, terminology alignment, artifact validation, and implementation planning.