Solution Modules

Primary Modules

The Prior Authorization Solution is composed of three main modules with additional dependencies:

The CRD and PAS modules provide the APIs, orchestration and request routing for the CRD, DTR and PAS APIs. These modules do not implement the actual rules. A fully operational solution requires integration with back end systems provided by the Payer or optionally implemented using modules such as CQL backed DTR. The CRD and PAS modules include an embedded Camel component. This component is responsible for routing the incoming API calls to the appropriate back end endpoints. The Camel component can also invoke custom Processors to enable translation such as X12 to FHIR.

• Coverage Requirements Discovery (CRD): The CRD operation 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.
  • The CRD Module works in conjunction with the CDS Hooks module. The CRD operation is actually a CDS Hooks call. The when CRD Module starts it registers itself as a handler for certain types of hooks (e.g. order-sign)
• Prior Authorization Submission (PAS):
  • This module requires a FHIR Endpoint and a FHIR Repository
  • The PAS Module registers the following operations
    • DTR Related:
      • Questionnaire/$questionnaire-package
      • Questionnaire/$next-question
    • PAS Related:
      • Claim/$submit
      • Claim/$inquire
      • ClaimResposne/$shd.pa.submit
• DaVinci Data Exchange
  • In the context of Prior Auth this module supplies the $submit-attachment operation used by Providers to upload additional information after a Prior Auth request is submitted.

Supporting Modules

• CQL Backed DTR (Documentation Templates and Rules (Formerly known as DTR Module)
  • This module allows for implementation of Prior Auth rules and documentation requirements using our CQIS suite. From the perspective of the overall Prior Auth deployment this module should be treated as a back end system invoked by the camel coordination layer in one of the main modules

Standards & 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.