CleanVues CMS SUITE
Comply with all CMS 0057-F requirements and go further to unlock greater value from your data strategy.
MEET THE REQUIREMENTS
CleanVues Health ensures payers meet the complex and detailed requirements of the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). Implementing the solution involves integrating the necessary APIs, adhering to the USCDI (United States Core Data for Interoperability) standard for data classes and elements, and following the recommended Da Vinci Implementation Guides (IGs). The Cleanvue CMS Suite is a comprehensive solution that complies with all standards and recommendations, transforming business operations through automated prior authorization.
KEY FEATURES
The CMS Suite includes the ePA API, which is populated with the following:
Payer’s list of covered items and services: Cleanvue’s solution verifies in real-time at the point of care whether Prior Authorization (PriorAuth) is required.
Documentation requirements for PriorAuth approval: CleanVues can automatically generate a request-specific questionnaire, pre-populating responses directly from EHRs.
PriorAuth request and response support: Cleanvue’s workflow enables providers to submit requests and receive real-time responses, including approvals, denials with reasons, or requests for additional information.
CleanVues CMS Suite features a complete ePA module that powers an entirely automated PA process through our Clinical Reasoning Engine. Automating the PA process with CDS (Clinical Decision Support) workflows reduces operational costs for both payers and providers, while enhancing patient satisfaction for your members.
The automated Payer-to-Payer workflow ensures seamless care continuity by making claim, encounter, and prior authorization data from one payer accessible to another. Payers are required to share patient data within five years of the request, and concurrent payers must exchange data quarterly. Additionally, payers must provide members with the option to opt into this data exchange.
CleanVues CMS Suite not only helps payers meet these requirements but also ensures secure high-volume data exchange through advanced patient matching, consent management, and robust security features.
Originally established in the CMS-9115-F Rule, this FHIR-based service enables 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 prior authorization information for their members.
CleanVues out-of-the-box solution is easy to implement. Its CMS reporting and audit capabilities allow payers to submit patient or member usage metrics annually, ensuring compliance with the mandate requirements.
This API enables the sharing of patient data—including claims, clinical, and prior authorization information—with relevant in-network providers. Payers must offer members the option to opt out, ensuring control over whether their data is made available to other providers.
CleanVues solution ensures secure and compliant data sharing by managing identification, authorization, and consent, safeguarding the data from payers, providers, and members/patients.
As part of the CMS-9115-F Rule, payers are required to make provider directory information publicly accessible through a FHIR-based API. This ensures transparency and helps members easily find care and treatment options. The API also enables clinicians to identify other providers for effective care coordination.
CleanVues easy-to-integrate API allows payers to provide this crucial information seamlessly, putting it at the fingertips of their members.