The Documentation Requirement LookUp Service Project

Medicare only pays for items and services when the provider’s medical record documentation indicates that all coverage and coding requirements were met. The Medicare documentation requirements appear in various locations and on separate websites causing burden to providers who must navigate the various websites to find coverage requirements, including documentation and prior authorization requirements.

CMS built a FHIR-enabled Medicare Fee for Service (FFS) Documentation Requirement Lookup Service DRLS so that providers can discover Medicare FFS prior authorization and documentation requirements:

• At the time of service

• Within their electronic health record (EHR) or integrated practice management system

For example, providers can answer questions such as:

• Is prior authorization required by Medicare FFS for the item or service for which I’m about to refer my patient?

• Does Medicare FFS have documentation requirements for the item I’m about to order for my patient?

CMS-0057 requires that by 1/1/2027, all CMS-regulated payers to build and operate a FHIR-enabled DRLS similar to Medicare FFS’.

Combs-Dyer Consulting is helping:

• Payers get ready to build a DRLS compliant with CMS-0057,

• Providers get ready to submit transactions to their payers’ DRLS systems.