Medical Oncology Prior Authorization (MOPA): A Standards-Based Framework for Medical Oncology Prior Authorization (PSS-2782)

Project Name
Medical Oncology Prior Authorization (MOPA): A Standards-Based Framework for Medical Oncology Prior Authorization (PSS-2782)

Project Number
1972

Project Type

Product Family

Products

Project Intent

Ballot Type

Project Need

The Medical Oncology Prior Authorization project will develop guidance for organizations implementing FHIR-based prior authorization workflows for medical oncology (chemotherapy-based) treatment. CMS 0062-P posits use of the Da Vinci FHIR APIs for impacted payers for drugs covered under the medical benefit - which incorporates cancer treatments that are oral or infused. As such, the timing of this guidance is opportune to support use of interoperable standards.  

Medical oncology is a distinct PA use case because the unit being evaluated is the anti-cancer regimen as a coordinated treatment plan, not just an individual drug, infusion, or service. Regimens may include multiple drugs, cycle days, sequential phases, and treatment timing that must be understood together. Medical oncology PA is therefore regimen centered and context dependent in ways that current drug or procedure-level workflows do not represent well.  

Further, oncology treatment guidelines are complex, change quickly, and vary among payers, providers, and guideline authorities. The ability to add transparency into the guidelines and payer policies (drug preferences) at play will be fundamental to automating and removing burden in PA for oncology.  

This work aligns with CMS-0057-F, which established FHIR-based prior authorization requirements for non-drug items and services, and CMS-0062-P, which proposes to extend similar interoperability requirements to drugs, including chemotherapeutics and anti-cancer agents. No current interoperability standard adequately addresses the clinical context that oncology drug authorization requires. This project is intended to fill that gap. 

This project will work closely with the Da Vinci Burden Reduction CRD, DTR, PAS, and CDex projects, including participating in project calls, to ensure that additional needed oncology data elements and capabilities agreed upon by the provider and payer communities are reflected in future versions of those guides and that any oncology-specific implementation guidance is also included within those guides.  This project may also produce its own publications outside the scope of those guides, such as recommendations on using AI to assist in assessing oncology-related claims, or extensions to the mCODE specification.

Objectives and Deliverables
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Project Document Repository

Collaboration Efforts
ASCO, AMA, Hike Health, Intersect OncoHealth, Oracle, NCPDP, PhenoML, SamaCare, Vermonster, UHC

Dependencies
Da Vinci APIs mCODE

Stakeholders
Consultant,EHR, PHR Vendors,Health Care IT Vendors,Health Care IT,Healthcare Institutions (hospitals, long term care, home care, mental health),Lab Vendors,Patients,Payer/Third Party Administrator,Payors,Providers,Standards Development Organizations (SDOs)

Implementers
Vermonster, Hike Health, OncoHealth

External Drivers
CMS-0062-P (proposed April 2026) extends prior authorization requirements to prescription drugs, including chemotherapeutics and anti-cancer agents. For the first time, health plans face federal requirements to support structured, electronic prior authorization for the drug classes at the center of oncology care. No interoperability standard currently exists that adequately addresses how to exchange the clinical context — regimen, stage, biomarkers, line of therapy — that oncology drug authorization actually requires.

Common Names
MOPA

Lineage

External Vocabularies

Backwards Compatibility

Joint Copyright