Using the PAS (Prior Auth Support) API

This tutorial demonstrates how an in-network provider can interact with a payer using PAS FHIR APIs. It covers submitting a new Prior Authorization request, checking its status, and handling the payer’s response.

Payers expose the following PAS API operations for in-network providers:

• Claim/$submit – Submit a new Prior Authorization request
• Claim/$inquire – Check the status of a Prior Authorization request

Payers can leverage the following Smile custom operation to update a Prior Authorization response:

• ClaimResponse/$sdh.pa.submit – Update an existing Prior Authorization response (approvals, denials, or requests for additional information) generated during a Prior Authorization request.

Submit a New Prior Authorization Request

To submit a new Prior Authorization request, use the Claim/$submit operation.

HTTP Request:

POST [PAYER_BASE_URL]/Claim/$submit
Content-Type: application/fhir+json
Authorization: Bearer <ACCESS_TOKEN>

Request Body:

The body of the POST request must contain the PAS Request Bundle as a FHIR collection bundle. It should include:

• One or more Claim resources (as the first entry)
• Any referenced resources

For detailed definitions of the PAS Request Bundle and examples, refer to the PAS Request Bundle Profile.

Response

After submitting the request, a PAS Response Bundle is returned synchronously. This should happen within a maximum of 15 seconds from submission to receiving the response, including network time.

• If the authorization cannot be fully evaluated within this timeframe, one or more requested items may be 'pended'.
• A subscription-based mechanism can be used to receive updates when the authorization is finalized. or use the Claim/$inquire operation to query for updates or final results.

For detailed specifications and examples, refer to the PAS Response Bundle Profile.

Check the Status of a Prior Authorization Request

Providers can check the status of a previously submitted Prior Authorization using the Claim/$inquire operation.

HTTP Request:

POST [PAYER_BASE_URL]/Claim/$inquire
Content-Type: application/fhir+json
Authorization: Bearer <ACCESS_TOKEN>

Request Body:
The body of the POST request must contain the PAS Inquiry Request Bundle as a FHIR collection bundle. It should include:

• One or more Claim resources (as the first entry) for which the status is requested.
• Any referenced resources

For detailed specifications and examples, refer to the PAS Inquiry Request Bundle Profile.

Response:

A PAS Inquiry Response Bundle is returned synchronously. The response contains the current status of the requested authorization(s).

• Items may be 'pended', 'approved', or 'denied' depending on the adjudication state.

For detailed specifications and examples, refer to the PAS Inquiry Response Bundle Profile.

Update a Prior Authorization Response

Payers can leverage the Smile custom operation, ClaimResponse/$sdh.pa.submit, to send adjudication responses for Prior Authorization requests, including approvals, denials, or requests for additional information.

HTTP Request:

POST [PAYER_BASE_URL]/ClaimResponse/$sdh.pa.submit
Content-Type: application/fhir+json
Authorization: Bearer <ACCESS_TOKEN>

Request Body:

The body of the POST request must contain a PAS Response Bundle as a FHIR collection bundle. It should include:

• One or more ClaimResponse resources (as first entry)
• Any referenced resources

For detailed specifications and examples, refer to the PAS Response Bundle Profile.

Response:
The operation returns a single FHIR Bundle containing the submitted ClaimResponse and any referenced resources. In case of errors, an OperationOutcome resource is returned. For more detailed infomation, refer to the Da Vinci Prior Authorization Support FHIR IG.