Electronic Medical Record Systems: Enhancing Data Access and Streamlining Prior Authorizations

As part of the new Centers for Medicare and Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F), Highmark is introducing advanced new capabilities, beginning Jan. 1, 2027, for electronic medical record (EMR) systems.

These enhancements will streamline the prior authorization process by integrating it directly into compatible EMR workflows. Depending on your EMR’s capabilities and connection readiness, you’ll be able to:

• Instantly check authorization needs
• Get clear documentation requirements
• Submit and track authorizations from your EMR

Note: For certain services, providers who qualify for Highmark’s Gold Carding Program may receive expedited prior authorization with immediate approval.

Access Highmark Health Records for Your Patients

The new Provider Access Application Programming Interface (API) securely delivers providers with a comprehensive view of a patient’s Highmark health journey. Available to providers with a treatment relationship with the patient (subject to patient data-sharing preferences), this view includes:

• Claims and encounter data
• Prior authorization history
• Clinical information, such as lab results and diagnostics

Empowering Patients

Through the Highmark member portal (myHighmark.com), members have direct control over their data and can grant permissions that enhance the continuity of their care. Patients can consolidate their health history, control data sharing with providers, and use an app of their choice.

 A Guide for Technical Teams and EMR Vendors

To realize the full benefits of these interoperability mandates, your EMR systems will need to securely integrate with Highmark's forthcoming FHIR-based* APIs. Providers should initiate discussions with their internal technical teams and EMR vendors to prepare for these capabilities and monitor the Provider Resource Center (PRC) for onboarding and support updates.

Our upcoming technical rollout will feature several key APIs designed to automate your workflows:

• Coverage Requirements Discovery (CRD): Automatically determines if a prior authorization is required for a specific patient, service, and plan at the point of care.
• Document Templates and Rules (DTR): Retrieves the specific clinical documentation requirements and rules directly into your EMR when a prior authorization is flagged as necessary.
• Prior Authorization Support (PAS): Enables the direct submission, updating, and status tracking of prior authorization requests entirely from within your EMR workflow.
• Provider Access API: Facilitates the secure retrieval of available Highmark patient information directly into your systems. This includes claims, encounter data, prior authorization, and clinical information.

Next Steps

Highmark’s dedicated Developer Portal for the 2027 CMS mandates, which will contain all technical specifications and implementation guides, is under construction. We’ll provide updates and a direct link to the portal as soon as it’s ready.

*FHIR is an acronym for Fast Healthcare Interoperability Resources.