OmniCompli

CMS Suite+

CMS SUITE+

Enterprise-Scale Prior Authorization Automation and Rule Governance

OmniCompli CMS Suite+ extends the foundational capabilities of the CMS Suite with enterprise-scale prior-authorization automation and consolidated rule governance. It enables payers to operationalize computable policy logic across compliance, utilization management, and delegated partner ecosystems using a unified FHIR® and CQL foundation.

Where CMS Suite ensures standards-conformant execution of CMS-0057-F mandate APIs, CMS Suite+ adds deterministic prior authorization adjudication, centralized policy management, and high-throughput automation aligned to Da Vinci Implementation Guides. It builds on the same unified rules engine foundation, enabling scalable compliance infrastructure prepared for future regulatory demands.

Organizations operating multiple, complex regulatory and operational compliance programs across a wide network benefit from a unified foundation that doesn’t add technical complexities.

Smile Digital Health is Drummond Group certified for CMS-0057-F.

Compliance in Isolation Creates Complexity at Scale

Approaching CMS-0057-F as a discrete IT project separate from operations, propagates the same fragmented implementations that have plagued healthcare IT for decades. The focus on enforcement dates and standing up APIs, misses the intention and long-term effort the CMS rules are attempting to enforce. This leaves governance, compliance data quality, and workflows disconnected across internal departments. Disparate compliance efforts often fail to serve the full provider network (especially out-of-network providers), burden internal teams with additional point solutions, and undermine payer-provider collaboration. Ticking the compliance check-box without a unified FHIR platform and implementation strategy can mean that Payers misses the opportunity to leverage this investment as a foundation for broader workflow automation, better governance, and operational intelligence.

There is incredible strategic and operational value to have data ingested from all Provider EHRs and external delegates. Payers who have not yet engaged or tested solution integration with their Prior Authorization Delegates and Providers may add to their risk and complexity.

Innovation Opportunities That CMS Suite+ Makes Possible

With CMS Suite+, Payers can both meet the CMS-0057-F requirements today, and build foundations that accelerate moving beyond compliance tomorrow, with less technical and operational effort.

With OmniComli CMS Suite+ organizations build upon the modernization foundation of CMS Suite, and in addition, can:

• Automate PriorAuth with FHIR® and Da Vinci IGs
  CMS Suite+ includes network-wide real-time PriorAuth automations for both in and out of network providers. The solution delivers accurate and defensible real-time adjudications using Da Vinci IGS for CRD, DTR, and PAS, all executed on a FHIR and CQL foundation. Automated, standards-based prior authorization supports faster, more predictable decisions, enabling timely patient care and reducing administrative burden and delays between payer-provider workflows.

Real-time PA decisions powered by FHIR and Da Vinci yield real-time adjudication, less payer-provider friction and on-time care delivery.

• Operationalize Prior Authorization with Computable Policy Logic
  Smile enables payers to author and execute prior authorization policies using FHIR and Clinical Quality Language (CQL). Together FHIR and CQL support real-time, deterministic adjudication at the point of care. Unlike probabilistic AI approaches, computable policies are explainable, traceable, and defensible. A deterministic AI approach accelerates policy authoring into FHIR and CQL, reducing administrative burden while preserving compliance integrity.

Deterministic AI automation built for transparency, traceability, beyond regulatory compliance.

• Move Beyond Mandates Without Rebuilding Your Stack
  CMS-0057-F is one milestone in a longer interoperability and automation journey. The same FHIR and CQL foundation that supports compliance also enables organizations to extend into automated real-time PriorAuth, evolving CMS requirements, and new payer–provider workflows, without re-platforming or duplicating effort. Compliance capabilities become reusable building blocks, not isolated implementations.

Embed compliance as required infrastructure for further innovation, not a one-off compliance check-list.

Trust is in The Data

• 255K+ Transactions processed per second
• 3 Months Complete CMS implementation for large pay-vider (200k+ staff)
• 30+ Payers using OmniCompli
• 70% Reduction in PriorAuth burden through auto-adjudication
• 100M+ American Lives - Impacted across BCBS network implementations

Calculate PriorAuth Savings Across Your Network

CMS Suite+ Includes

OmniCompli CMS Suite+ delivers pre-built, FHIR-compliant APIs to meet federal mandates (CMS-0057-F and beyond) turning regulatory check-boxes into innovation building blocks. With real-time prior authorization adjudication enabled, Payers can meet the June 2025 Prior Authorization Pledge as well. This compliance package includes:

• Electronic Prior Authorization (ePA) API: Seamless ePA adjudication automation process that includes Da Vinci CRD, DTR and PAS IGs to accurately adjudicate requests and determine decisions
• Provider Access API: Shareability of all member data with in-network providers, including identification modules, proper authorization and secure consent management.
• Patient Access API: Publicly available PA metrics, details and decisions, with embedded report and audit capabilities.
• Payer-to-Payer API: Automated workflows between payers to enable continuity of care, with security safeguards, consent modules, ID matching, and secure high-volume data exchange.
• Provider Directory API: Publicly available and searchable provider directory using FHIR-based APIs to make better care decisions.

Explore OmniCompli

Explore the enterprise-level compliance foundation engine with CMS Suite and Smile-managed CMS compliance outcomes with CMS Concierge.

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