TriZetto Payer Prior Authorization Solution Overview

This document is a guide detailing the TriZetto Payer Prior Authorization Solution designed to assist organizations in complying with the CMS Advancing Interoperability and Prior Authorization Processes Final Rule (CMS-0057). The solution aims to streamline prior authorization workflows by enhancing existing APIs and supporting new APIs for government and public health plans. It outlines the functionalities of the solution, including informing providers about prior authorization requirements, identifying necessary documentation, and facilitating the submission of authorization requests. The guide also explains how the solution orchestrates data exchanges between providers' EHR systems and health plans, adhering to HL7 FHIR standards and Da Vinci implementation guides. Key capabilities such as Coverage Requirements Discovery, Documentation Templates and Rules, and Prior Authorization Support are described, emphasizing the solution's role in improving efficiency, accuracy, and compliance in prior authorization processes. The document concludes with a note on the expertise of Cognizant in regulatory compliance and interoperability.