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January 23, 2023

Acronym Anxiety? Get the FAQs About Top Terms Related to Prior Authorization Software

by Susan Lawson-Dawson | Healthcare Technology, Prior Authorization

You can’t deny that acronyms, abbreviations, and unusual lingo abound in healthcare. Add technology to the mix, and you’re wading into a confusing alphabet soup of terms. We tackled a few in our blog about the Da Vinci standards. Today,  we’ll expand on words you may run across when exploring prior authorization software options. 

Key Players in the Interoperability Arena 

CMS: In addition to being the “payer” for millions of Americans, the Centers for Medicare and Medicaid, aka CMS, plays a central role in advancing interoperability and reducing the administrative burdens. Those administrative burdens contribute an estimated 15-25% of total healthcare spending in the US—not to mention distract clinicians from their real purpose: patients. The latest proposed rule from the CMS, “Advancing Interoperability and Improving Prior Authorization Processes” tackles one of the biggest burdens of all: Today’s most-manual prior authorization process. 

HIIG: The Health Informatics and Interoperability Group is part of the CMS. It oversees CMS interoperability efforts for the express purpose of “… the secure exchange, access, and use of electronic health information to support better informed decision making and a more efficient healthcare system.”

HIMSS: The Healthcare Information and Management Systems Society provides advisory services and thought leadership related to reforming healthcare globally “through the power of information and technology.”  Its membership includes 430+ providers, 500+ nonprofit partners, 550+ health services organizations and 120,000 individuals from around the world. 

HL7: HL7 standards for Health Level Seven International, an accredited standards developing organization founded in 1987. HL7 focuses on developing frameworks and standards for data integration and exchange of electronic health information. You’ll see it used in combination with acronyms that appear in the next section. 

Tech Terms Related to Prior Authorization Software  

FHIR: FHIR stands for Fast Healthcare Interoperability Resources. Introduced by HL7 and developed collaboratively with other stakeholders, HL7 FHIR dictates the standards for exchanging data based on specific use cases. FHIR establishes a worldwide protocol for transmitting health data, regardless of the systems in use.  Based on widely-used internet standards, FHIR lower barriers to entry and enables real-time, secure data sharing via APIs.  

API: An Application Programming Interface makes data exchange possible, allowing different systems and applications to communicate and share data.  

EDI:  Electronic Data Interchange refers to computer-to-computer exchange of business documents

HIE: Health Information Exchange describes electronic sharing of health-related data between two or more organizations. It depends on data standardization and technologies to enable use by a variety of healthcare stakeholders. In addition, the term describes organizations that facilitate the secure exchange and use of data to support public health.

HITRUST CSF: Aggregating regulations and expert guidance from numerous sources, including HIPAA, Health Information Trust Alliance or HITRUST has developed a comprehensive, Common Security Framework (CSF) for data security and privacy.  The organization offers three assessment levels for organizations : Self-assessment, CSF validated, and CSF-certified. Myndshft is proud to have met the highest standards to achieve HITRUST CSF-certified status. 

Healthcare Acronyms that Pop Up Regularly

HIPAA: Also known as the Health Insurance Portability and Accountability Act of 1996, this rule addresses the use and disclosure of individuals’ health information by entities subject to the Privacy Rule, also known as “covered entities.” Furthermore, the Privacy Rule contains standards for individuals’ rights to understand and control how their health information is used.

PHI: Protected Health Information stands for personally identifiable health information that is regulated and protected by HIPAA.  

EHR:  Electronic Healthcare Records contain patients’ records from multiple doctors, providing a holistic, long-term view of a patient’s health. Beyond describing the data, EHR also refers to the system which houses such data (Epic, Oracle Cerner, etc.). 

EMR: Electronic Medical Record is best understood as a digital version of a patient’s chart. It contains the patient’s medical and treatment history from one practice. 

HCPCS: Healthcare Common Procedure Coding System reflects standardized, alphanumeric procedure code sets necessary for Medicare and other health insurance providers to provide healthcare claims. Similar to and in some cases overlapping with NDC (National Drug Code). (See NDC, CPT.)

ICD-10: Maintained by the World Health Organization, ICD-10 stands for International Classification of Diseases. This updates the previous ICD-9 codes and is a diagnostic tool for epidemiology, health management and clinical purposes.

What acronyms and terms leave you scratching your head? 

Let us know which ones you’d like to see next time. In the meantime, you can get more familiar with the lingo with our Ultimate Guide to Prior Authorizations