On this page:
   63.0    Overview
  • Explanation
  • 63.0 Overview
  • 63.1 Solution Modules & Standards
  • 63.2 Actors, Roles & Data Scope
  • 63.3 Use Cases & Timeliness
  • 63.4 Security
  • 63.5 Glossary of Terms
    • 63.2    Actors, Roles & Data Scope   
    Table of Contents

    Solution Modules & Standards

    63.1.1Solution Modules

     

    The Prior Authorization Solution is composed of three integrated modules, each addressing a key part of the prior authorization workflow:

    • Coverage Requirements Discovery (CRD): Determines whether a prior authorization is required for a service or procedure. This helps providers avoid unnecessary requests, reduces administrative overhead, and ensures compliance with payer requirements.
    • Documentation Templates and Rules (DTR): Provides templates and rules to ensure requests include all necessary clinical information. This module helps standardize documentation and improves the likelihood of approvals on first submission.
    • Prior Authorization Submission (PAS): Facilitates the submission, tracking, updating, and cancellation of prior authorization requests. PAS handles interactions with payers and intermediary systems, including conversion between FHIR and X12 formats when required, and ensures that requests and responses are compliant with relevant standards.

    Together, these modules support the end-to-end prior authorization lifecycle from discovery to final response.

    63.1.2Standards & Technology

     

    The Prior Authorization Solution is built on HL7 FHIR R4 and leverages the following Da Vinci Implementation Guides (IGs):

    • Da Vinci Coverage Requirements Discovery (CRD)
    • Da Vinci Documentation Templates and Rules (DTR)
    • Da Vinci Prior Authorization Support (PAS)

    This standards-based approach ensures interoperability between payer and provider systems, supporting secure, real-time communication and regulatory compliance.

       63.0    Overview
  • Explanation
  • 63.0 Overview
  • 63.1 Solution Modules & Standards
  • 63.2 Actors, Roles & Data Scope
  • 63.3 Use Cases & Timeliness
  • 63.4 Security
  • 63.5 Glossary of Terms
    • 63.2    Actors, Roles & Data Scope