ZettaYotta EHR Emulator for CMS-0057

DaVinci Burden Reduction for Prior Auth

Version: v1.0 — Hover CDS (2025-10-05)

A concise, educational walkthrough of the Coverage Requirements Discovery (CRD) → Documentation Templates and Rules (DTR) → Prior Authorization Support (PAS) flow. 👩‍⚕️ Clinician selects a 👤 patient, chooses an order, completes documentation. If medical necessity is established during DTR, the PAS request can be auto‑approved; otherwise a 👩‍💼 payer clerk may pend for more information or deny with rationale.

1. CRD 👩‍⚕️
2. DTR 👤
3. PAS 👩‍💼

Electronic Health Record (EHR)
Coverage Requirements Discovery (CRD)

CDS Hooks: order-select
Story: 👩‍⚕️ Physician/clinician selects a 👤 patient and enters an order. The Electronic Health Record (EHR) calls the payer's Coverage Requirements Discovery (CRD) service via CDS Hooks. The payer returns a card indicating whether prior authorization is likely and provides a Launch DTR link when documentation is needed.

Documentation Templates and Rules (DTR)

SMART on FHIR
Story: 👩‍⚕️ Clinician completes payer-required documentation with the 👤 patient context. Questions are adaptive and change based on the selected code and prior answers.

Use Launch DTR (Documentation Templates and Rules) from a Coverage Requirements Discovery (CRD) card to open the documentation form.

Prior Authorization Support (PAS)

FHIR Claim / ClaimResponse
Story: A 👩‍💼 payer clerk (utilization management) reviews the Prior Authorization Support (PAS) request. If medical necessity is clearly established during DTR finalization, the request may be auto‑approved; otherwise the payer may pend for more info or deny with rationale.

Submit from DTR to see the payer decision.