Prior Auth Support Module
Prior Authorization Support (PAS) is a Smile CDR module that enables the direct submission of prior authorization requests from EHR systems. It streamlines and automates the prior authorization process between healthcare providers and payers, ensuring efficient, interoperable, and secure management of authorization requests.
Built on Fast Healthcare Interoperability Resources (FHIR) standards and aligned with HL7 Da Vinci Prior Authorization Support (PAS) implementation guidelines (IG), the PAS module enhances the prior authorization workflow with several key features.
Smile CDR supports the PAS IG with the following operations:
Claim/$submit is used to submit a prior authorization request for adjudication. It accepts a single Bundle resource as input, which includes the PAS Claim Request along with any referenced resources. The output is either a single Bundle resource containing the PAS Claim Response and any referenced resources or an OperationOutcome resource in case of errors.
URL: [base]/Claim/$submit
| Use | Parameter | Type | Cardinality | Description |
|---|---|---|---|---|
| IN | PAS Request Bundle | Resource | 1..1 | A Bundle containing a single Claim and referenced resources. |
| OUT | PAS Response Bundle or OperationOutcome (in case of error) | Resource | 1..1 | A Bundle containing a single ClaimResponse and referenced resources, or an OperationOutcome in case of errors. |
Claim/$inquire is used to check the status of prior authorization requests. It accepts a single Bundle resource as input, which includes the PAS Claim Inquiry Request along with any referenced resources. The output is either a single Bundle resource containing the PAS Claim Inquiry Response and any referenced resources or an OperationOutcome resource in case of errors.
URL: [base]/Claim/$inquire
| Use | Parameter | Type | Cardinality | Description |
|---|---|---|---|---|
| IN | PAS Inquiry Request Bundle | Resource | 1..1 | A Bundle containing a single ClaimInquiry and referenced resources. |
| OUT | PAS Inquiry Response Bundle or OperationOutcome (in case of error) | Resource | 1..1 | A Bundle containing a single ClaimInquiryResponse and referenced resources, or an OperationOutcome in case of errors. |
ClaimResponse/$sdh.pa.submit is a custom Smile CDR operation that allows the payers to send their responses to prior authorization requests, including authorization decisions such as approvals, denials, or requests for additional information. It accepts a single Bundle resource as input, which includes the PAS ClaimResponse along with any referenced resources. The output is also a single Bundle resource containing the PAS ClaimResponse and any referenced resources, or it may return an OperationOutcome resource in case of errors.
URL: [base]/ClaimResponse/$sdh.pa.submit
| Use | Parameter | Type | Cardinality | Description |
|---|---|---|---|---|
| IN | PAS Response Bundle | Resource | 1..1 | A Bundle containing a single ClaimResponse and referenced resources. |
| OUT | PAS Response Bundle or OperationOutcome (in case of error) | Resource | 1..1 | A Bundle containing a single ClaimResponse and referenced resources, or an OperationOutcome in case of errors. |
To route the PAS Requests from healthcare providers to the payer, the following components are used:
FHIR Subscription are used to track PAS Request Bundles from Claim/$submit as they are created and updated in the FHIR repository, then pushing them to the payer-preferred message broker (i.e., Kafka or ActiveMQ).
{
"resourceType": "Subscription",
"id": "profile-pas-request-bundle",
"status": "active",
"criteria": "Bundle?_profile=http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle",
"channel": {
"type": "message",
"endpoint": "channel:<indicate channel name>",
"payload": "application/json"
}
}
The Message Broker is a messaging system used as the communication channel to transmit prior authorization requests and updates to the payer. PAS Request Bundles, including new requests and updates, are pushed to this broker and then consumed by the payer to initiate the adjudication process.