A Working API Does Not Prove the Workflow Works
The authorization request went through. The patient is still waiting. Where did the process stop? Consider a provider requesting authorization for a patient’s treatment. Staff first check the health plan’s coverage requirements to determine what the request needs. They then gather supporting clinical evidence and submit the request. The payer reviews the information and returns a decision or asks for more information. Staff then need to understand the response, track the request status, and determine what happens next. Finally, they must explain that next step to the patient. A working API may support the connection, but one broken handoff can still send staff back to a portal, fax, or phone call. CMS encourages providers to test with EHR vendors and payer partners before the January 2027 requirements take effect.
Test the Whole Authorization Journey
Programs need to test what staff can actually do with their tools. Can staff see requirements? Can they submit evidence? Can they understand a denial? Can they track status? Can they explain the next step? These questions show whether staff can complete the work after the API responds. CMS identifies access to coverage and documentation requirements, electronic submission and tracking, and reduced reliance on portals and fax as goals of electronic prior authorization.
HITS Tests Critical Handoffs
Health Information Technology Solutions (HITS) LLC maps payer and provider handoffs into clear requirements. We develop scenarios for routine requests and exceptions. We support integration and user testing to identify workflow gaps. We trace defects through testing and connect test evidence to release decisions. HITS applies federal health integration QA, requirements, and traceability experience to these efforts.
Workflow Testing Exposes Operational Gaps
Testing shows where staff leaves the intended workflow. It exposes missing evidence, unclear decisions, broken status updates, and exception paths that require manual work. Early testing gives programs time to address these gaps before they affect daily operations. CMS encourages early testing to identify gaps, validate workflows, build technical readiness, and improve the experience for patients and staff.
Prove the Workflow Before You Scale
Federal health programs need evidence before leaders declare the workflow ready. Realistic scenarios should test routine requests and exceptions. Named owners should address problems at each handoff. Defect records should map where the workflow failed, and retest results should show whether fixes worked. HITS helps programs connect requirements, workflow testing, defects, and release decisions. This provides leaders with the confidence they need to declare the workflow ready.
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