Answer prior authorisation requests in seconds from the medical record
Most cancer drug approvals depend on a handful of facts already in the chart, such as the diagnosis, biomarker and line of therapy; sending those automatically in a standard format would return most decisions before the patient leaves the room.
Overview
CMS's 2024 Interoperability and Prior Authorization final rule requires payers to offer electronic prior authorisation through HL7 FHIR interfaces and to decide urgent requests within 72 hours and standard ones within seven days from 2026 and 2027. Oncology criteria are structured (diagnosis, stage, biomarker, prior lines), so the mCODE data standard can carry them. Payers publishing their oncology rules as computable criteria, and electronic records sending mCODE bundles, turns a fax-and-phone process into an automated one with human review only for exceptions.
- Fragmented care and guideline gaps · Patients fall between specialists, wait for referrals and often do not get the treatment guidelines say they should.
- Data silos · Records, scans, genomes and outcomes sit in separate systems that cannot talk. Every patient's experience is lost to the next.
- Not enough oncologists, nurses, pathologists, physicists · The number of people with cancer is rising faster than the workforce trained to treat them.
Pages like this
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