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SMILE CMS SUITE


Meet all the requirements of CMS 0057-F, and go beyond to get more value from your data strategy.

MEET THE REQUIREMENTS

Smile Digital Health ensures that payers meet all the complex and nuanced requirements of the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). Implementing a solution requires integrating the APIs, listed below,  adherence with the USCDI (United States Core Data for Interoperability) standard for data classes and elements, as well as recommended Da Vinci IGs (Implementation Guides). The Smile CMS Suite is a comprehensive solution that adheres to all standards and recommendations, and transforms business operations with automated prior authorization.

  • Electronic Prior Authorization (ePA) 
  • Payer to Payer (P2P)
  • Patient Access
  • Provider Access
  • Provider Directory

Electronic Prior Authorization (ePA) 

The CMS Suite includes the ePA API which must be populated with:

- The payer’s list of covered items and services - Smile’s solution confirms a whether PriorAuth is required or not, in real-time at the point of care.

- Identification of documentation requirements for PriorAuth approval - Smile can automatically generate a request-specific questionnaire that can pre-populate responses directly from EHRs.

- Support a PriorAuth request and response - Smile’s workflow allows providers to submit requests and receive real-time responses, including approval, denial and reason, or requests for additional information.


Smile’s CMS Suite includes a complete ePA module which builds a truly automated PA process powered by our Clinical Reasoning Engine. Automating the PA process with CDS (Clinical Decision Support) workflows reduces operational expenses for payers and providers, while creating enhanced patient satisfaction for your members.

Payer to Payer (P2P)

The automated Payer to Payer workflow enables care continuity, by making claim, encounter, and prior authorization data from one payer available to another. Payers are required to share patient data with a date of service within five years of the request. Concurrent payers are required to exchange data quarterly. Payers need to offer members the ability to opt-into this data exchange.

Smile’s CMS Suite not only allows payers to meet these requirements, but also safeguards high-volume data exchange through patient matching, consent and security features.

Patient Access

Originally established in the CMS-9115-F Rule, this FHIR-based service allows patients (members in a payer’s network) to easily access their clinical, claims, and encounter data through third-party applications of their choice. The new CMS-0057-F Rule now requires payers to include information about prior authorizations to their members.  

Smile’s out-of-the box solution is easy-to-implement. Its CMS report and audit capabilities allow payers to submit patient or member usage metrics annually in accordance with the mandate requirements.

Provider Access

This API allows the patient data—including claims, clinical and prior authorization information—to be shared with relevant in-network providers. Payers must offer members an opt-out feature, enabling sovereignty of having their data available to other providers.

Smile’s solution accounts for identification, proper authorization and consent keeping data from payers, providers and members/patients secure and compliant. 

Provider Directory

As part of the CMS-9115-F Rule, payers are required to make provider directory information publicly available via a FHIR-based API. Payers are required to offer transparency and support members in their search for care and treatment. This API also enables clinicians to find other providers for care coordination.

Smile’s quick and easy-to-integrate API allows payers to make this information available at their members’ fingertips. 

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BENEFITS OF SMILE CMS SUITE

Automate your workflow

By accelerating prior authorization processes without delays.

Enhance data flow

By integrating Smile’s solutions with your existing systems without delays.

Optimize your operations

By reducing payer and clinical PA burden by up to 70%*, and allowing teams to focus on complex cases, instead of manual reviews.

*AHIP study

Receive new insights

To power enhanced decision-making by leveraging structured data and our Clinical Reasoning Engine.

Improve patient care

Receive higher STAR ratings and HEDIS scores by providing just-in-time, event-driven care.

Save up to $3.30/ member**


On operational costs with Auto Adjudication.


**2022 CAQH Index Reports

LEARN ABOUT THE CMS-0057F RULE AND WHAT PAYERS NEED TO DO TODAY TO BE COMPLIANT!

SMILE, ON EVERY STEP OF YOUR JOURNEY

Your organization’s journey to compliance is unique. Whether you need an out-of-the-box product, or some basic API integrations to fit within your existing tech stack, you need a flexible solution and an experienced implementation partner to help you achieve compliance in a timely manner. You also need a partner that can take you beyond compliance, to transform your business by streamlining operations to create integrated ecosystems, so that you can unlock new, valuable insights from your data and receive better ROI.

WHY CHOOSE SMILE DIGITAL HEALTH

Built for Compliance

In 2021, Smile successfully implemented CMS-9115-F requirements for over 20 payers, impacting over 100 million US lives. Our payer clients chose us as the #1 vendor of choice. Today, Smile’s CMS Suite delivers complete compliance with the CMS-0057-F mandate.

Highly Customizable

We offer modular implementation, so that any or all of our compliance modules, listed above, can seamlessly fit into your existing system.

Scale and Performance

Our solution is highly performant and scalable across massive payer networks. This is proven by our ability to bulk ingest over 2 billion FHIR resources in under 26 hours, at a ground-breaking speed of 255,000 transactions per second.

Built for the Future

Our interoperability and compliance solution suite is customizable for your requirements today and because we are built upon a FHIR-native Health Data Platform, upgradable for your needs tomorrow. 

Industry Trusted

Smile Digital Health achieved the Drummond certification after rigorous interoperability testing of our end-to-end functionality.

Drummond Payer and Patient Access Compliance Certificate_SmileCDR_Nov2021

 

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