66.2.1Using 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 leverage the following Smile custom operation to update prior authorization responses:

• ClaimResponse/$sdh.pa.submit – Sends adjudication responses (approvals, denials, or requests for additional information) for prior authorization requests.

66.2.2Submit 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
• 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 happens 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.

66.2.3Check 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 a PAS Inquiry Request Bundle as a FHIR collection bundle. This bundle should reference the Claim resources for which the status is requested.

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.

66.2.4Update a Prior Authorization Response

Payers 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
• 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.