Delaware launched a single hub for electronic prior authorizations. Here's why.

Looking beyond compliance

Electronic prior authorization is designed to replace paper-and fax-based workflows with digital transactions. But replacing faxes with electronic connections does not eliminate the underlying complexity.

"Instead of having fax machines connecting things, we'll have electronic connections, but we'll have a million electronic connections," said Neil Hochstein, M.D., Delaware's surgeon general. "We'll replace a fax machine with a modernized version."

Providers often maintain separate connections with multiple health plans, creating a web of interfaces Hochstein described as "like spaghetti."

Delaware state officials saw the CMS-0057 mandate as an opportunity to address the broader interoperability challenge through a central hub, rather than simply meeting the federal deadline for electronic prior authorization.

"Prior authorization is just the start," Hochstein said, pointing to public health reporting, claims adjudication and other administrative transactions as potential uses for this shared infrastructure.

One connection instead of many

Instead of asking every provider and payer to connect directly to one another, Smart Health Network provides a shared hub that organizations connect to once, while keeping the CMS-0057 APIs and systems they are already building.

Paul Meyer, CEO of Smart Health Network, likened the approach to payment networks such as Visa.

"Visa is a three-way hub that connects a consumer, a bank and a merchant," Meyer said. "Everybody connects once."

Like Visa, Smart Health Network routes transactions but does not access their contents. Meyer described each transaction as a sealed envelope: the network knows where it needs to go and delivers it, but cannot open or read what is inside.

Smart Health Network is structured as a public benefit corporation and designed to operate as a neutral utility. The governance model allows competing payers, providers and technology companies to connect to shared infrastructure without any single participant controlling the network.

Hochstein said the structure includes both a data trust and a governance trust, with the goal of keeping participation affordable rather than maximizing revenue.

"The purpose is not to monetize it," Hochstein said. "The purpose is not to extract the highest rent possible, but to find the lowest sustaining cost possible." 

Using existing infrastructure to accelerate adoption

Delaware is using DHIN's existing relationships with providers to spread awareness of the Smart Health Network and help them get connected. Hochstein said healthcare practices across the state already know and trust DHIN, giving the HIE an established network of provider relationships to build on.

"We can leverage their trust and their network," Hochstein said. "I don't mean electronic network. I mean their people network."

While many organizations will be able to connect to the network through designated gateway hosts, including EHR vendors and cloud providers, some smaller organizations with limited IT resources will be able to use DHIN as the gateway host.

That flexibility allows organizations to participate without replacing existing systems or abandoning the CMS-0057 work already underway.

Working toward interoperability together

Delaware may be the first to organize a statewide implementation of the Smart Health Network, but providers and payers elsewhere do not have to wait for states to launch it.

Organizations across the country can begin testing now while continuing to build the CMS-0057 capabilities required for the January 2027 deadline. In fact, the day after the network launched in Delaware, individual organizations outside the state, including HIEs and payers, joined a CMS Connectathon to connect to and test the network.

For organizations preparing for CMS-0057, the question is no longer whether to build electronic prior authorization capabilities, but whether to build them one trading partner at a time or through a shared network.

For Meyer, the answer is straightforward. Instead of organizations building these interoperability capabilities independently, they should be testing against the shared infrastructure available.

"They're dancing alone," Meyer said. "They should be dancing with others."

Elizabeth Stricker, BSN, RN, comes from a nursing and healthcare leadership background, and covers health technology and leadership trends for B2B audiences.