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Health data company Smile Digital Health and MCG Health are partnering in a move that will help payers meet the requirements of the Centers for Medicare and Medicaid Services Interoperability and Prior Authorization Final Rule.
The final rule takes effect in stages starting in 2026 with requirements for Payer-to-Payer API starting on Jan. 1, 2027.
The partnership integrates MCG care guidelines and the MCG Path compliance offering with Smile's HL7 Fast Healthcare Interoperability Resources (FHIR)-first health data platform.
Smile and MCG, which is part of the Hearst Health Network, are members of the HL7 Da Vinci Project, which began developing FHIR-based interoperability standards for prior authorization automation in 2018.
Via the alliance, Smile Digital Health will integrate MCG Path, a FHIR-based application programming interface that aims to deliver MCG care guideline content, with the Smile CMS Suite, which the company describes as an offering that adheres to all standards and recommendations and transforms business operations with automated prior authorization.
Smile and MCG's integration will back three workflows recommended under the CMS final rule: coverage requirements discovery, documentation templates and rules, and prior authorization support.
In a joint statement, the two companies said that by integrating MCG's clinical content directly into Smile's platform via MCG Path's APIs, payer organizations will be able to streamline clinical review processes, automate documentation and lower the administrative burden on providers and their internal teams.
Additionally, the Smile-MCG integration allows payer organizations to clarify provider workflows with standards-based documentation requirements; permit faster, automated prior authorization determinations utilizing MCG's evidence-based content; consolidate and standardize review processes; and support CMS compliance by installing FHIR-based APIs directly into clinical workflows.
"MCG listens to its customers and we believe this partnership will further enhance how payers and providers collaborate to support the patient," said Jon Shreve, president and CEO of MCG Health, by statement. "This partnership will promote informed authorization decisions for health plan members."
Duncan Weatherston, CEO of Smile Digital Health, noted that the partnership with MCG represents a pivotal step in making prior authorization faster and more transparent for payers, providers and patients.
"By embedding MCG Path's evidence-based clinical content directly into Smile's FHIR-first platform, we are helping organizations support compliance with CMS-0057-F, reduce administrative burden and improve care delivery," Weatherston said in a statement.
THE LARGER TREND
Earlier this week, MCG Health and Avo launched a new AI assistant that aims to reduce hospital length of stay.
The companies' collaboration allows MCG to integrate recovery milestones from its proprietary guidelines into electronic health record workflows through Avo's newest assistant.
In 2024, Cohere Health and MCG Health integrated their content and technology offerings to enhance the prior authorization process for providers, patients and health plans.
The aim was to integrate MCG care guidelines into Cohere's Unify Decisioning tool to build a solution for prior authorization decision-making, driving higher rates of clinically relevant auto approvals while decreasing provider submission time and friction.
The partnership was designed to benefit joint health plan clients, their provider networks and patients.
As a result of the integration, health plan clinical review staff members can view indications, pre-filled by Cohere models within MCG Cite CareWebQI.
In February, Smile Digital Health secured a $15 million credit financing agreement with FirePower Capital. The partnership enabled Smile to accelerate the growth and expand its offerings.
